by Robin Cook
Kelley’s most notable feature and by far the dominant aspect of his profile was his enormous paunch. Every night three bottles of stout contributed to its awe-inspiring dimensions. For the last few years it had been pointed out that when Kelley was vertical, his belt buckle was horizontal.
Gerald Kelley had worked for the Memorial since he was fifteen years old. He had started out in the maintenance department, the boiler room to be exact, and now he was in charge. From his long experience and mechanical aptitude he knew the power plant of the hospital inside and out. In fact, he knew almost all the mechanical aspects of the building by heart. It was for this reason that he was in charge and also why he was paid $13,700 a year. The hospital administration knew he was indispensable, and they would have paid more if Gerald Kelley had made an issue of it. The fact was, each party was satisfied.
Gerald Kelley sat at his desk in the machinery spaces of the basement, thumbing through work orders. He had a day crew of eight men, and he tried to distribute the work according to need and capability. Any work on the power plant itself, though, Kelley did himself. The work orders in front of him were all routine, including the drain in the nurses’ station on the fourteenth floor. That plugged up on schedule, once per week. Placing the work orders in the sequence he felt they should be done, Kelley began to match them up with his crew.
Although the general din in the machinery spaces was at a relatively high level, especially for people unaccustomed to the area, Kelley’s ears were sensitive to the character of the mixed sounds. Thus when the clank of metal on metal reached his ears from the direction of the main electrical panel, he turned his head. Most people would not have heard the sound amid all the other mechanical noises. However, it did not repeat itself and Kelley returned to his administrative job at hand. He did not like the paperwork attached to his position; he would have preferred to fix the sink on the fourteenth floor himself. Yet he also understood that organization was a necessity if he were to keep things running. There was no way he could attend to every repair himself.
The clank recurred, louder than before. Kelley turned again and surveyed the area near the electrical panel, behind the main boilers. He returned to his papers but found himself staring ahead, trying to understand what could have caused the kind of sound he had heard. It had a sharp, brief metallic resonance foreign to the indigenous sounds of the area. Finally curiosity got the best of him and he wandered over to the main boiler. To get near to the electrical panel situated next to the main chase, which contained all the piping rising up in the building, he had to go around the boiler in either direction. He chose to go right, which gave him an opportunity to check the gauges on the boiler. This was an unnecessary maneuver because the system had been fully automated with backup safety devices and automatic cutoff switches. But it was an instinctive move for Kelley, having originated in the days when the boiler had to be watched minute by minute. So as he rounded the boiler his eyes were on the system, his mind appreciating its marvelous compactness compared to the system when he had started at the Memorial. When he looked ahead toward the electrical panel, he froze in his tracks, his right arm lifted involuntarily in self-defense.
“God, you scared the life out of me,” said Kelley, catching his breath and allowing his arm to come back to his side.
“I could say the same,” said a slim man dressed in a khaki uniform. The shirt was open at the neck, and the man wore a white crew neck T-shirt which reminded Kelley of navy chiefs during his wartime duty. The man’s left breast pocket bulged with pens, small screwdrivers, and a ruler. Above the pocket was embroidered “Liquid Oxygen, Inc.”
“I had no idea anyone else was in here,” said Kelley.
“Same with me,” said the man in khaki.
The two men looked at each other for a moment. The man in khaki was carrying a small green cylinder of compressed gas. A flow meter was attached to the cylinder head. “Oxygen” was stenciled plainly on the side.
“My name is Darell,” said the man in khaki. “John Darell. Sorry to have scared you. I’ve been checking the oxygen lines out to the central storage tank. Everything seems fine. In fact, I’m on my way out. Could you tell me the shortest route?”
“Sure. Through those swinging doors, up the stairway to the main hall. Then you have a choice. Nashua Street is to the right, Causeway Street to the left.”
“Thanks a million,” said Darell, heading for the door.
Kelley watched him leave, and then looked around in disbelief. He couldn’t figure how Darell had managed to get where he had been without being noticed. Kelley had no idea he could get so absorbed in his Goddamn paperwork.
Kelley walked back to his desk and returned to work. After a few minutes he thought of something else that bothered him. There were no oxygen lines in the boiler room. Kelley made a mental note to ask Peter Barker, assistant administrator, about oxygen line checks. The trouble was that Kelley had a poor memory for everything except mechanical details.
Monday
February 23
3:36 P.M.
With the cloud cover Boston had enjoyed little daylight that day, and by 3:30 dusk settled over the city. It took a bit of imagination to comprehend that above the clouds shone the same six-thousand-degree fiery star which in summer turned the macadam on Boylston Street molten. The temperature had responded to the surrendering sun by precipitously falling to nineteen degrees. Another flurry of minute crystalline bodies wafted over the city. The outside lights along the hospital walkways had been on for almost a half-hour.
From within the illuminated library, it already appeared pitch black outside. The two-story window at the end of the room responded to the dropping temperature by starting an active convection current of cold air across its face. The weighted colder air fell to the floor at the foot of the window and then swept the length of the room under the tables toward the hissing radiators in the back. It was the cold current which first began to nudge Susan from the depths of her intense concentration.
As with so many academic subjects, Susan began to perceive that the more she read about coma, the less she felt she knew. To her surprise, it was an enormous subject, spanning many disciplines of medical specialization. And perhaps the most frustrating of all was Susan’s realization that it was not known what determined consciousness, other than saying that the individual was not unconscious. The definition of one consisted of being the opposite of the other. Such a tautologous circle was a travesty of logic until Susan accepted the fact that medical science had not advanced enough to define consciousness precisely. In fact, being fully conscious and being totally unconscious (coma) seemed to represent opposite ends of a continuous spectrum which included partway states like confusion and stupor. Hence the inexact, unscientific terms were more an admission of ignorance than poorly conceived definitions.
Despite the semantics Susan was well aware of the stark difference between normal consciousness and coma. She had observed both states that very day in a patient . . . Berman. And despite the lack of precision in definition, there was no lack of information regarding coma. Under the heading of “acute coma,” Susan began to fill page after page in her notebook with her characteristically small handwriting.
Her particular interest was in causation. Since science had not decided on what particular aspect of brain function had to be disrupted, Susan had to be content with precipitating factors. Being interested in acute coma, or coma of sudden onset, also helped to narrow the field but still was impressive and growing. Susan looked back over the list of causes that she had noted so far:
Trauma = Concussion, Contusion, or Any Type of Stroke
Hypoxia = Low Oxygen:
(1) MECHANICAL
—strangulation
—blocked airway
—insufficient ventilation
(2) LUNG ABNORMALITY
—alveolar block
(3) VASCULAR BLOCK
—blood cannot get to brain
(4) CELLULAR BLOCK OF OXY
GEN USE
High Carbon Dioxide
Hyper (Hypo) Glycemia = High (Low) Blood Sugar
Acidosis = High Acid in the Blood
Uremia = Kidney Failure with High Uric Acid in the Blood
Hyper (Hypo) Kalemia = High (Low) Potassium
Hyper (Hypo) Natremia = High (Low) Sodium
Hepatic Failure = Increase of Toxins Which Would Normally Be Detoxified by the Liver
Addison’s Disease = Severe Endocrine or Glandular Abnormality
Chemicals or Drugs . . .
Susan took an extra couple of pages for the chemicals and drugs associated with acute coma and listed them alphabetically, each with a separate line to make it possible to add information as she got it:
Alcohol
Amphetamines
Anesthetics
Anticonvulsants
Antihistamines
Aromatic hydrocarbons
Arsenic
Barbiturates
Bromides
Cannabis
Carbon disulfide
Carbon monoxide
Carbon tetrachloride
Chloral hydrate
Cyanide
Glutethimide
Herbicides
Hydrocarbons
Insulin
Iodine
Mercurial diuretics
Metaldehyde
Methyl bromide
Methyl chloride
Naphazoline
Naphthaline
Opium derivatives
Pentachlorophenol
Phenol
Salicylates
Sulfanilamide
Sulfides
Tetrahydrozaline
Vitamin D
Hypnotic agents
Susan knew that the list was not complete but nonetheless it gave her something to go on, something to keep in mind during her subsequent investigations, and it could be enlarged at any time.
Turning next to the general internal medicine textbooks, Susan opened the ponderous Principles of Internal Medicine and read the appropriate sections dealing with coma. The articles in Cecil and Loeb were about the same. Both books provided a rather good overview, although no new concepts were added. Several references were cited which Susan duly copied down in an ever-expanding list of necessary reading.
It felt good to get up and stretch. Susan allowed a deep comforting yawn. She wiggled her toes to try to encourage the blood to go there. The cold draft along the floor had made her stir sooner than she might have otherwise. But once up she turned to the Index Medicus, the exhaustive listing of all articles published in all the medical journals.
Starting with the most recent volumes and working backward, Susan searched for and extracted every article concerning acute coma and every article under the heading “Anesthetic complications: delayed return to consciousness.” By the time she had worked herself back to 1972, Susan had a list of thirty-seven prospective papers worth reading.
One title especially caught Susan’s attention: “Acute Coma at the Boston City Hospital: A Retrospective Statistical Study of Causes,” Journal of the American Association of Emergency Room Physicians, volume 21, August 1974, pp 401-3. She found the bound volume containing the article and was soon immersed in it, taking notes as she read.
Bellows had to call her by name before she looked up at him. He had come into the library, located her, and had taken the seat directly across from her. But she did not look up from her reading. Bellows had tried clearing his throat with absolutely no effect. It was as if Susan were in a trance.
“Dr. Susan Wheeler, I believe,” said Bellows, leaning over the table, his shadow falling across the journal in front of her.
Susan finally responded and looked up. “Dr. Bellows, I presume.” Susan smiled.
“Dr. Bellows is right. God, what a relief. I thought for a moment you were in a coma.” Bellows shook his head up and down, as if he were agreeing with himself.
Neither one of them spoke for a few moments. Bellows had prepared a short speech during which he was going to correct any impression he might have given Susan that she was free to cut lectures. He had decided to tell her in plain language that she had to get her ass in gear. But once confronting her, sense of purpose failed, leaving him as directionless as a sailboat becalmed. Susan remained silent because her intuition had informed her that Bellows had something to say. The silence soon became mildly awkward.
Susan broke it.
“Mark, I’ve been doing a bit of interesting reading here. Look at these figures.”
She stood up and leaned across the table, holding out the journal so that Bellows could see the page. As she did so, her blouse fell away from her chest. Bellows found himself staring down at her splendid breasts, barely contained by a sheer flimsy bra, their skin of a smoothness Bellows imagined to be like velvet. He tried to concentrate on the page Susan was showing him, but his peripheral vision continued to record the insistent image of Susan’s lovely torso. Self-consciously Bellows scanned the library, certain that his preoccupation would be transparent to anyone in the room.
Susan was oblivious to the mental havoc she was inadvertently causing.
“This chart here shows the order of incidence of the various types of acute fatal coma appearing at the emergency room at the Boston City Hospital,” said Susan, running her fingers along the lines. “One of the most amazing facts is that only fifty percent of the cases are ever diagnosed. I find that amazing; wouldn’t you agree? That means that fifty percent of the cases are never diagnosed. They just come in to the ER in coma and die. Just like that.”
“Yeah, it’s amazing,” said Bellows, putting his left hand up to his temple to try to keep from seeing what he was seeing.
“And look here, Mark, at the causes of the cases which they do diagnose: sixty percent are due to alcohol, thirteen percent due to trauma, ten percent to strokes, three percent to drugs or poisons, and the rest divided up among epilepsy, diabetes, meningitis, and pneumonia. Now obviously . . . ,” said Susan, sitting back down and relieving the stress on Bellows’s hypothalamus.
Bellows glanced around once more to make sure that no one had noticed the episode.
“. . . we can dismiss alcohol and trauma as far as causing acute coma in the OR is concerned. So . . . that leaves us with strokes, then drugs or poisons, and the others in decreasing probability as possible culprits.”
“Wait a second, Susan,” said Bellows pulling himself together. He put his elbows on the table with his forearms up in the air, his hands drooped but engaged. His head was down at first, then he picked it up and looked at Susan. “That’s all very interesting. A little farfetched, but interesting.”
“Farfetched?”
“Yeah. You cannot possibly extrapolate data from the ER to the OR. But anyway, I didn’t come in here looking for you to argue about that. I came in here because you haven’t been answering your pages. I know, because it was me who was paging you. Look, I’m going to have trouble if you don’t show up for conferences. You’re going to make trouble for yourself, and the fact of the matter is that, while you’re on my service, your trouble is my trouble. I can only make excuses for you for so long. I mean, you can be drawing blood or scrubbing just so often. Stark will be asking questions before you know it. He’s phenomenal. He knows everything that’s going on around here. Besides, you’ll get the reputation of being a phantom among your own section students. Susan, I’m afraid you’re going to have to restrict your research proclivities to after-hours.”
“Are you finished?” asked Susan, rising to the defense.
“I’m finished.”
“Well, answer me this one question. Has Berman or Greenly awakened yet?”
“Of course not . . .”
“Then frankly, I believe that my current activities eclipse the importance of a few boring surgical conferences.”
“Oh my aching back! Susan, be reasonable. You’re not going to save the world during your first week on surgery. I’m going out
on a limb for you as it is.”
“I appreciate it, Mark. Really I do. But listen. My few hours here in the library have already provided some very interesting information. The complication of prolonged coma after anesthesia is about one hundred times more prevalent here at Memorial than the incidence given for the rest of the country over the past year. Mark, I think I’m onto something. When I started, it was more of an emotional thing which I thought I could work out in a day or two here in the library. But one hundred times! God, I could be on the track of something big, like a new disease, or a lethal combination of normally safe drugs. What if this is some sort of viral encephalitis, or even the result of a previous infection which makes the brain somehow more susceptible to certain drugs or mild lack of oxygen?”
Susan had been part of the medical world for only two years, and yet she was already cognizant of the potential benefits which would accrue to someone who discovered a new disease or syndrome. She thought this one might become known as the Wheeler syndrome, and Susan’s success within the medical community would be guaranteed. More often than not, the discoverer of the new disease became far more famous than the discoverer of the cure for the same disease. Eponyms abound in medicine like the tetralogy of Fallot, Cogan’s disease, the Tolpin syndrome, or Depperman’s degeneration. Whereas names like the Salk vaccine are an anomaly. Penicillin is called penicillin, not Fleming’s agent.
“We could call it the Free Wheeler Syndrome,” said Susan, allowing herself to laugh at her own enthusiasm.
“Christ,” said Bellows, cradling his head in his hands. “What an imagination. But that’s OK. Naiveté has a certain license. But, Susan, you are in a real world situation with certain specific responsibilities. You are still a medical student, low man—or woman—on the totem pole. You’d better get your tail in gear and honor your surgery rotation obligations or, believe me, your ass will be grass. I’ll give you one more day for this project, provided you show up for rounds in the morning. After that you work on it in your free time. Now, if I need you I’ll page Dr. Wheels instead of Wheeler, so answer it, understand?”
