Coma

by Robin Cook

  “That’s all that came out on this printout,” said Susan. “I wouldn’t be surprised if there were a few more if I had been able to call up the information straightaway.”

  “You really think so? God, eleven cases!” Bellows leaned over toward Susan, his tongue working at the empty spoon. “How’d you manage to get this IBM printout?”

  “Henry Schwartz was nice enough to help me,” said Susan nonchalantly.

  “Who the hell is Henry Schwartz?” asked Bellows.

  “Damned if I know.”

  “Spare me,” said Bellows covering his eyes with his hand, “I’m too tired for mental games.”

  “Is that a chronic ailment or an acute affliction?”

  “Cut the crap. How’d you get this data? Something like this has to be cleared through the department.”

  “I went upstairs this afternoon, filled out one of those M804 forms, gave it to the nice man at the desk, and then went back tonight and picked it up.”

  “I’m sorry I asked,” said Bellows getting up and waving his spoon to suggest he would let the issue ride. “But eleven cases. Did they all happen during surgery?”

  “No,” said Susan, going back to the printout. “Harris was on the level when he said six. The other five were from inpatients on the medical service. Their diagnosis was idiosyncratic reaction. Doesn’t that strike you as pretty odd?”

  “No.”

  “Oh, come on,” said Susan impatiently. “The word idiosyncratic sounds great but it really means that they had no idea what the diagnosis was.”

  “That might be true, but Susan, dear, this happens to be a major hospital, not a country club. It serves as a referral base for the whole New England area. Do you know how many deaths we have here on an average in a single day?”

  “Deaths have causes . . . these cases of coma do not . . . at least not as yet.”

  “Well, deaths don’t always have apparent causes. That’s the purpose of autopsy.”

  “There, you hit the nail on the head,” said Susan. “When someone dies, then you do an autopsy and you find out what was the cause of death so that you can possibly add to your fund of knowledge. Well, in the coma cases you can’t do an autopsy because the patients are somewhere hovering between life and death. That makes it even more important that you do another kind of ‘opsy,’ a live-opsy, if you will. You study all the clues you have available, short of dismembering the victim. The diagnosis is just as important, maybe even more important than the autopsy diagnosis. If we could find out what was wrong with these people, maybe we could bring them out of their comas. Or better still, avoid the coma in the first place.”

  “Even the autopsy,” said Bellows, “doesn’t always provide the answers. There are plenty of deaths where the exact cause is never determined whether they do an autopsy or not. I happen to know that two patients threw in the towel today, and I doubt very much if a diagnosis will be made.”

  “Why do you think that the diagnosis won’t be made?” asked Susan.

  “Because both patients expired from respiratory arrest. They apparently just stopped breathing, very calmly with no warning. They were just discovered dead. And in respiratory arrest you don’t always find anything to hang the blame on.”

  Bellows had captured Susan’s interest. She was staring at him without moving, without blinking.

  “Are you OK?” asked Bellows, waving his hand in front of her face. Still Susan did not move until she looked down at the IBM printout.

  “What the hell do you have, psychomotor epilepsy or something?” asked Bellows.

  Susan looked up at him. “Epilepsy? No, of course not. You said these cases today died of respiratory arrest?”

  “Apparently. I mean they stopped breathing. They just gave up.”

  “What were they in the hospital for?”

  “I’m not positive. I think one of them was in for some problem with his leg. Maybe he had phlebitis and they might find a pulmonary embolus or something. The other one was in for Bell’s palsy.”

  “Were they both on I.V.s?”

  “I don’t remember but I wouldn’t be surprised if they had been. Why do you ask?”

  Susan bit her lower lip, thinking about what Bellows had just told her.

  “Mark, do you know something? These deaths you mentioned could be related to the coma victims.” Susan patted the printout with the back of her hand. “You might have hit on something. What were the names? Can you remember?”

  “For Christ’s sake, Susan, you’ve got this thing on the brain. You’re working overtime and you’re starting to have delusions.” Bellows switched to an artificially concerned tone. “Don’t be concerned, though; it happens to the best of us after we’ve stayed up for two or three nights in a row.”

  “Mark, I’m serious.”

  “I know you’re serious, that’s what worries me. Why don’t you give yourself a break and forget about it for a day or so? Then you can pick it up and be more objective. I tell you what. I’ve got tomorrow night off and with a little luck I can get out of here by seven. How about some dinner? You’ve only been here a day but you have to get away from the hospital as much as I do.”

  Bellows hadn’t planned on asking Susan out quite so soon and in such a fashion. But he was pleased because it had come so apparently spontaneously and consequently it would be easy to deal with a refusal if it occurred. It sounded more like an offer to get together than an actual date.

  “Dinner’s fine, can’t pass up an offer for a dinner even with an invertebrate. But really, Mark, what were the names of the two deaths today?”

  “Crawford and Ferrer. They were patients on Beard 6.”

  Susan pursed her lips as she wrote the names down in her notebook. “I’ll have to look into those in the morning. In fact . . .” Susan looked at her watch” . . . maybe tonight. If they were going to do an autopsy on these cases, when would it be?”

  “Probably tonight or first thing in the morning,” shrugged Bellows.

  “Well then I better check tonight.”

  Susan refolded her printout.

  “Thanks, Mark, old boy; you’ve been a help again.”

  “Again?”

  “Yeah. Thanks for those articles you Xeroxed for me. You’ll make a good secretary someday.”

  “Up yours.”

  “Tut, tut. See you tomorrow night. How about the Ritz? I haven’t eaten there for several weeks,” teased Susan, heading for the door.

  “Not so fast, Susan. I’ll see you at rounds in the morning at six-thirty. Remember our deal. I’ll cover for you another day if you come to rounds.”

  “Mark, you’ve been such a dear, really. Let’s not louse it up so soon.” Susan smiled and pulled some of her hair across her face with coquettish exaggeration. “I’ll be up till all hours reading all this material you got for me. I need one more full day. We’ll discuss it further tomorrow night.”

  Then she was gone. Again Bellows felt encouraged about Susan as he sipped his coffee. Then he got up. He had plenty of work to do.

  Monday

  February 23

  8:32 P.M.

  The pathology lab was in the basement of the main building. Susan descended the stairs and emerged in the middle of a basement corridor which disappeared into utter darkness to the right and twisted out of view to the left. Stark bare lightbulbs glowed from the ceiling at intervals of twenty to thirty feet. The light from each bulb met the light from the next in an uneasy penumbra, causing a strange interplay of shadows from the tangle of pipes along the ceiling. In a vain attempt to provide color to the dim subterranean world, angled stripes of bright orange paint had been painted on the walls.

  Directly opposite Susan, partially hidden from view, was an arrow pointing to the left, with the word Pathology stenciled above it. Susan turned down the corridor, her shoes making hollow noises on the concrete floor, competing with the hiss of the steam pipes. The atmosphere was oppressive; the location within the bowels of the hospital was sinisterly a
ppropriate. She was not heading for the pathology lab with any favorable anticipation. As far as Susan was concerned pathology represented the black side of medicine, the specialty that seemed to derive its nourishment from medical failure, death. Arguments about the benefits of biopsies which the pathologists analyzed or the obvious beneficial spinoffs for the living from the autopsies the pathologists performed were all lost on Susan. She had only seen one autopsy done during her course in pathology, and that had been one too many. Life had never seemed quite so fragile nor had death seemed quite so final as when Susan had watched the two overweight pathologists disembowel the body of a recently deceased patient.

  The memory of that event slowed Susan’s steps but it did not halt them. She was determined. But she had seemingly been walking for a hundred yards as the corridor twisted first in one direction then in another. She cast a nervous glance over her shoulder, wondering if she could have missed the door to the lab. With increased misgivings she continued. At several places, the lightbulbs were not functioning and Susan’s shadow would appear in front of her and lengthen. Then as she moved into the sphere of influence of the next functioning light her shadow would pale and disappear.

  Finally she faced two swinging doors. The upper portion of each contained opaque windows.

  “Unauthorized Entry Forbidden” was lettered boldly across the cracked, frosted glass on each door. Stenciled in peeling gold paint below the window on the right door was “Pathology Laboratory.” Susan hesitated at the door, building up her confidence, wondering what sort of scene to prepare herself for. Cracking the door, she got a glimpse of the interior. A long black stone table dominated the room, running most of its length. Cluttered about on the table were microscopes, slides, slide boxes, chemicals, books, and an array of other equipment. Susan pushed open the door and stepped into the lab. The acrid smell of formaldehyde hung over the room.

  The entire wall on the right had shelving from floor to ceiling. With hardly a square inch remaining, the shelves were full of varying sized bottles and jars. Looking more closely, Susan realized that the amorphous colorless mass in the large jar closest to her was an entire human head cut neatly in half, sagitally. Just behind the halved tongue in the wall of the throat was a granular mass. The label on the glass simply said, “Pharyngeal carcinoma, #304-A6 1932.” Susan shuddered and tried to keep herself from glancing at other equally gruesome specimens.

  At the far end of the room was another set of swinging doors identical to those from the corridor. From the room beyond, Susan could hear a mixture of voices and metallic sounds. She walked toward the doors as silently as possible, feeling herself an intruder in an alien and potentially hostile environment.

  Susan tried to peer through the crack between the doors. Although her visual field was limited she knew immediately that she was looking into the autopsy room. Slowly she began to open the left door.

  A loud ringing noise echoed around the room causing Susan to spin around, letting the autopsy room door snap shut behind her. At first she thought that she had tripped some alarm system and she felt the urge to bolt for the door into the corridor. But before she could move, a pathology resident appeared out of another side door.

  “Well, hello there,” said the resident to Susan as he walked over to the sink and picked up a distilled water irrigator. He smiled at Susan as he squirted water over a tray of slides he was staining. The color went from deep violet to clear. “Welcome to the path lab. You a med student?”

  “Yes.” Susan forced a smile.

  “We don’t see many med students this time of day . . . or night. Is there anything special we can do for you?”

  “No, not really. I’m just looking around. I’m quite new here,” said Susan putting her hands in the pockets of her white coat, her pulse racing.

  “Make yourself at home. There’s coffee in the office here if you’re interested.”

  “No thanks,” said Susan walking back along the desk, aimlessly touching some of the slide boxes.

  The resident added another amber stain to the tray of slides and reset the timer.

  “Actually, maybe you could help me,” said Susan fingering a few slides on the table. “Several patients from Beard 6 expired today. I wondered if they’ve been . . . um . . .” Susan tried to think of the right word.

  “What were the names?” asked the resident wiping his hands. “There’s a post going on right now.”

  “Ferrer and Crawford.”

  The resident walked over to a clipboard hanging from a nail on the wall.

  “Hmmm . . . Crawford. That rings a bell. I think that was a medical examiner’s case. Here’s Ferrer . . . that’s a medical examiner’s case. And I was right, Crawford is too. They’re both medical examiner’s cases, but hold on.”

  The resident walked quietly over to the doors into the autopsy room and banged one open with the palm of his hand. With his right hand holding the edge of the remaining closed door he leaned into the room beyond, his head just out of Susan’s view.

  “Hey, Hamburger, what’s the name of the case you’re doing?”

  There was a pause and a voice but Susan could not hear it.

  “Crawford! I thought that was an examiner’s case.” There was another pause.

  The resident came back into the room as the timer went off again. The ringing noise made Susan jump once more. The resident squirted more distilled water onto the slides.

  “The medical examiner released both cases to the department, as usual. Lazy son of a bitch. Anyway they’re doing Crawford right now.”

  “Thanks,” said Susan. “All right if I go in and take a look?”

  “By all means, our pleasure,” said the resident, shrugging his shoulders.

  Susan paused momentarily at the doors, but she knew the resident was watching her, so she pushed open one of the doors and entered the room.

  The room was probably forty feet square, old and dingy. Its walls were surfaced in white tile, which was ancient, cracked, and missing in places. The floor was a type of gray terrazzo. In the center of the room there were marble tables built with slanted tops. A stream of water constantly ran down each table toward a drain at the foot, which emitted a constant sucking noise. Over each table hung a hooded light, a scale, and a microphone. Susan found herself standing on a level three to four steps above the level of the main floor. Immediately to her right were several wooden benches on progressively lower tiers. These benches were a remnant from older days when groups would assemble to observe autopsies.

  Only one of the hooded lights was on, that over the table nearest to Susan. It cast its relatively narrow beam down onto the naked corpse on the table immediately below. On each side of the table stood a pathology resident wearing an oilcloth apron and rubber gloves. The focal point of light caused the rest of the room to slide into graded burnt umber shadow like a sinister Rembrandt painting. The table in the center of the room was in shadow but it was possible for Susan to see that it also held a naked corpse, a manila tag tied around its right big toe. A large Y-shaped sutured incision crossed the thorax and abdomen. The third table was barely visible in the darkness, but it appeared to be empty.

  Susan’s entrance stopped all progress in the room. Both residents were staring at her with their heads tilted down to avoid the glare of the overhead light. One of the residents with a large moustache and sideburns, was in the process of suturing the Y-shaped incision on the male corpse under the light. The other resident, taller by almost a foot, was standing before a basin containing the disemboweled organs.

  Having sized up Susan, the taller resident went back to work. He reached into the tangle of organs with his left hand, grasping the liver. His right hand gripped a large, razor-sharp butcher knife. A few strokes freed the liver from the other organs. The liver made a sloshing sound as it oozed into the scale. The resident stepped on a foot pedal on the floor, speaking into the microphone. “The liver appears reddish brown with a lightly mottled surface, period. The gross we
ight is . . . a . . . two point four kilograms, period.” He then reached into the pan and lifted the liver out, dropping it back into the basin.

  Susan descended several steps toward the group. The smell was slightly fishy; the air seemed greasy and heavy, like an uncleaned bus depot restroom.

  “The liver consistency is more firm than usual but definitely pliant, period.” The knife flashed in the light and the liver surface separated. “The cut surface demonstrates an enhanced lobar pattern, period.” The knife sliced across the liver in four or five more places, then finally cut a piece out of the center. “The cut specimen demonstrates the usual friable character, period.”

  Susan moved up to the foot of the table. The sucking drain was directly in front of her. The taller resident on the left reached into the basin for another organ but he stopped when the moustached resident spoke.

  “Well, hello . . .”

  “Greetings,” said Susan, “sorry to bother you.”

  “No bother. Join the party, except we’ve almost finished.”

  “Thanks, but I’m happy to just watch. Is this Crawford or Ferrer?”

  “This is Ferrer,” said the resident. Then he pointed at the other body. “That’s Crawford.”

  “I was wondering if you’ve determined a cause of death.”

  “No,” said the taller resident. “But we haven’t opened the lungs on this case yet. Crawford was clean grossly. Maybe the microscopic sections will shed some light.”

  “Do you expect something in the lungs?” asked Susan.

  “Well, from the history of apparent respiratory arrest, we were considering pulmonary embolism. But I don’t think we’re going to find anything, though. Maybe there’ll be something in the brain sections.”

  “Why don’t you think you’ll find anything?”

  “Well, because I’ve posted a few cases like this before, and I’ve never found anything. And the history is exactly the same. Relatively young, somebody comes by and they’re not breathing. There’s a resuscitation attempt but without luck. Then we get them, or at least after the medical examiner turns them over to us.”