Coma

9

Monday, February 23, 12:34 P.M.

For Susan Wheeler and the other four medical students, the charge down the hall to the elevator fitted perfectly their preconceptions of the excitement of clinical medicine. There was something horribly dramatic about the headlong rush. Startled patients sitting there casually leafing through old New Yorker magazines while waiting to see their doctors reacted to the stampeding group by drawing their legs and feet more closely to their chairs. They stared at the running figures who clutched at pens, penlights, stethoscopes, and other paraphernalia to keep them from flying from their pockets.

As the group came abreast of, then passed, each patient, the patient’s head swung around to watch the group recede down the corridor. Each assumed that a group of doctors had been called on an emergency, and it was reassuring for the patients to see how earnestly the doctors responded; the Memorial was a great hospital.

At the elevator there was momentary confusion and delay. Bellows repeatedly pushed the “down” button as if manhandling the plastic object would bring the elevator more quickly. The floor indicator above each elevator door suggested that the elevators were taking their own sweet time, slowly rising from floor to floor, obviously discharging and taking on passengers in the usual slow motion. For such emergencies there was a phone next to the elevators. Bellows snatched it off its cradle and dialed the operator. But the operator didn’t answer. It usually took the operators at the Memorial about five minutes to answer a house phone.

“Fucking elevators,” said Bellows striking the button for the tenth time. His eyes darted from the exit sign over the stairwell back to the floor indicator above the elevator. “The stairs,” said Bellows with decision.

In rapid succession the group entered the stairwell and began the long twisting plunge from the tenth floor to the second floor. The journey seemed interminable. Taking two or three steps at a time, constantly turning to the left, the group began to spread out a bit. They passed the sixth floor, then the fifth. At the fourth floor the whole group slowed to a cautious walk in the dark because of the missing light bulb. Then down again at the previous pace.

Fairweather began to slow and Susan passed him on the inside.

“I don’t know what the hell we are running for,” panted Fairweather as Susan passed.

Susan managed to brush her hair from her face, hooking ft behind her right ear. “As long as Bellows et al. are in the lead, I don’t mind running. I want to see what goes on but I don’t want to be the first one on the scene.”

Fairweather assumed a comfortable walk and was quickly left behind. Susan was nearing the third floor landing when she heard Bellows pound on the locked door on two. He yelled at the top of his lungs for someone to open the door, and his voice carried up the stairwell, reverberating strangely, taking on a warbling quality. As Susan rounded the final landing, the door on two was opened. Niles kept the door open for her and she entered the hall. The constant turning to the left in the stairwell made Susan feel a bit dizzy, but she did not stop. Following the others, she ran directly into the ICU.

In sharp contrast to the former dimness of the room, it was now brightly illuminated with stark fluorescent light that provided a shimmering aura to objects within the room. The white vinyl floor added to this effect. In the corner the three ICU nurses were engaged in giving closed chest massage to Nancy Greenly. Bellows, Cartwright, Reid, and the medical students crowded around the bed.

“Hold up,” said Bellows watching the cardiac monitor. The nurse giving the closed chest massage straightened up from her efforts. She was kneeling on the edge of the bed on the right side of Nancy Greenly. The monitor pattern was wildly erratic.

“She’s been fibrillating for four minutes,” said Shergood watching the monitor. “We started the massage within ten seconds.”

Bellows moved rapidly over to the right of Nancy Greenly and while watching the monitor, he thumped the patient’s sternum with his fist. Susan winced at the dull sound of the blow. The monitor’s pattern did not alter. Bellows began closed chest massage.

“Cartwright, feel for a pulse in the groin,” said Bellows without taking his eyes from the monitor. “Charge the defibrillator to 400 joules.” The last command was directed to anyone. One of the ICU nurses carried it out.

Susan and the other students backed up against the wall, acutely aware that they were mere observers, and although they wanted to, they could not help in the frantic activity occurring before them.

“You’ve got a good pulse going,” said Cartwright with his hand pressed in Nancy Greenly’s groin.

“Was there any warning for this or did it drop out of the blue?” said Bellows with some difficulty between compressions of the chest. He nodded his head toward the monitor.

“Very little warning,” answered Shergood. “She began to have a suggestion of increased excitability of her heart by having a few premature ventricular beats and a suggestion of a mild atrioventricular conduction defect which we picked up on the recorder.” Shergood held up a strip of EKG paper for Bellows to see. “Then she had a sudden run of extra systoles, and wham… fibrillation.”

“What has she got so far?” asked Bellows.

“Nothing,” said Shergood.

“OK,” said Bellows. “Push an amp of bicarbonate and draw up 10 cc of a 1:1000 epinephrine in a syringe with a cardiac needle.”

One of the ICU nurses injected the bicarbonate; another prepared the epinephrine.

“Somebody draw blood for stat electrolytes and calcium,” said Bellows, letting Reid take over the massage. Bellows felt the femoral pulse under Cartwright’s hand and was satisfied.

“From what Billings said at the complication conference on this case, the same thing is happening here that happened in the OR to cause all her troubles in the first place,” said Bellows thoughtfully. He took the 10 cc syringe with the epinephrine from the nurse, holding it up to let the last traces of air escape.

“Not quite,” said Reid between compressions. “She never fibrillated in the OR.”

“She didn’t fibrillate but she did have premature ventricular contractions. Obviously she had an excitable heart then as now. All right, hold up!” Bellows moved along Nancy Greenly’s left side, brandishing the syringe with the cardiac needle. Reid straightened up from his resuscitative efforts so that Bellows could feel along Nancy Greenly’s sternum for the landmark called the angle of Louis. Using that as a guide, he located the fourth interspace between the ribs.

The needle on Bellows’s syringe was three and a half inches long and a sparkle of reflected light danced off its stainless steel shaft. Decisively Bellows pushed it into the girl’s chest, all the way to the hilt. When the plunger was pulled back, dark red blood swirled up into the clear epinephrine solution,

“Right on,” said Bellows as he rapidly injected the epinephrine directly into the heart.

Susan’s skin crawled with the vivid thought of the long needle tearing its way down into Nancy Greenly’s chest and spearing the quivering mass of cardiac muscle. Susan could almost feel the coldness of the needle in her own heart.

“Go to it,” said Bellows to Reid as he stepped back from the bed. Reid immediately recommenced his cardiac massage. Cartwright nodded, indicating that there was a strong femoral pulse. “Stark is going to be pissed when he hears about this,” continued Bellows, eyeing the monitor, “especially right after his lecture on vigilance in these cases. Shit, I really don’t deserve this kind of headache. If she croaks, my ass is grass.”

Susan had trouble comprehending that Bellows had actually said what he did. Once again she was faced with the fact that Bellows and probably the entire crew were not thinking of Nancy Greenly as a person. The patient seemed more like the part of a complicated game, like the relationship between the football and the teams at play. The football was important only as an object to advance the position and advantage of one of the teams. Nancy Greenly had become a technical challenge, a game to be played. The final, ultimate result had become less important than the day-to-day plays and moves and ripostes.

Susan felt a strong surge of ambivalence toward clinical medicine. Her nascent female sensitivities seemed to be a handicap within the mechanistic and tactically oriented atmosphere. She silently longed for the old familiar lecture hall and its abstractions. Reality was too bitter, too cold, too detached.

And yet there was something fascinating and academically satisfying seeing the application of the basic scientific knowledge she had acquired. From physiology experiments with animal hearts, she comprehended the disorganization that the fibrillating heart within Nancy Greenly represented. If only the whole mass could be depolarized to stop all electrical activity, then the intrinsic rhythm could possibly begin again.

Susan strained to watch as Bellows placed the defibrillating paddles on Nancy Greenly’s exposed chest. One of the paddles was held directly over the sternum, the other was placed against the left lateral chest, slightly distorting the left breast with its pale nipple.

“Everyone away from the bed!” ordered Bellows. His right thumb made contact and a powerful electric charge spread through Nancy Greenly’s chest, arcing from one paddle to the other. Her body jerked upward; her arms flopped across her chest with her hands twisting inward. The electronic blip disappeared from the screen, then it returned. It traced a relatively normal pattern.

“She’s got a good pulse,” said Cartwright.

Reid held up on the external massage. The rate held steady for several minutes. Then a premature ventricular contraction appeared. The rate was again steady for several minutes followed by three premature ventricular contractions in a row.

“V tach,” said Shergood confidently. “The heart is still very easily excitable. There has to be something very basic wrong here.”

“If you know what it is, don’t keep it from us,” said Bellows. “Meanwhile let’s have some lidocaine, 50 cc.”

One of the nurses drew up the lidocaine and handed it to Bellows. Bellows injected it into the I.V. line. Susan moved so that she could see the monitor screen more clearly.

Despite the lidocaine, the rhythm rapidly deteriorated to senseless fibrillation once more. Bellows swore, Reid started massage, and the nurse recharged the defibrillator.

“What the hell is going on here?” queried Bellows, motioning for another amp of bicarbonate to be given. He didn’t expect an answer; he was posing a purely rhetorical question.

Another dose of epinephrine given I.V., followed by a second defibrillation attempt, returned the rate to a semblance of normal. But premature contractions returned, despite additional lidocaine.

“This has to be the same problem that they had in the OR,” said Bellows, watching the premature contractions increase in frequency until the rhythm dissolved into fibrillation. “You’re up again, Reid ole boy. Let’s go, team.”

By 1:15 Nancy Greenly had been defibrillated twenty-one times. After each shock a relatively normal rhythm would return only to disintegrate into fibrillation after a short duration. At 1:16 the ICU phone rang. It was answered by the ward clerk, who took the information. It was the lab calling with the stat electrolyte values. Everything was normal except the potassium level. It was very low, only 2.8 milliequivalents per liter.

The ward clerk handed the results to one of the nurses, who showed them to Bellows.

“My God! 2.8. How in Christ’s name did that happen? At least we have an answer. OK, let’s get some potassium in her. Put 80 milliequivalents into that I.V. bottle and speed it up to 200 cc per hour.”

Nancy Greenly responded to this command by immediately lapsing back into fibrillation for the twenty-second time. Reid started compression while Bellows readied the paddles. The potassium was added to the I.V.

Susan was totally absorbed by the whole resuscitation procedure. In fact, her concentration had been so great that she had almost missed hearing her name crackle out of the page system speaker near the main desk. The page system had been intermittently active throughout the entire cardiac arrest procedure by calling out the names of physicians followed by an extension number. But the sound had blended and merged with the general background noise, and Susan had been oblivious to it. At least until her own name floated out into the room along with the extension 381.

Somewhat reluctantly Susan left her place by the wall and used the phone at the main desk to answer her page.

381 turned out to be the extension of the recovery room and Susan was quite surprised to be paged from there. She gave her name as Susan Wheeler, not Dr. Susan Wheeler, and said that she had been paged. The clerk told her to hold the line. He returned immediately.

“There’s an arterial blood gas to be drawn on a patient up here.”

“Blood gas?”

“Right. Oxygen, carbon dioxide, and acid levels. And we need it stat.”

“How did you get my name?” asked Susan, twisting the cord on the phone. She hoped it was by some sort of mistake that she had been called.

“I just do as I’m told. Your name is on the chart. Remember it’s stat.” The line went dead. The clerk had hung up before Susan could respond again. Actually she had little else to say. She replaced the receiver and walked back to Nancy Greenly’s bedside. Bellows was repositioning the paddles again. The shock swept through the patient’s body, the arms ineffectually flopping across the chest. It seemed both dramatic and pitiful at the same time. The monitor showed a normal rhythm.

“She’s got a good pulse,” said Cartwright at the groin.

“I think she’s holding her sinus rhythm better now that some of the potassium has gotten into her system,” said Bellows, his eyes glued to the monitor screen.

“Dr. Bellows,” said Susan during the lull in the action. “I got a call to draw an arterial blood gas on a patient in the recovery room.”

“Enjoy yourself,” said Bellows, distracted. He turned to Shergood. “Where in heaven’s name are those medical residents? God, when you need them they lie low. But just try to take someone to surgery and they hang around like a group of vultures, canceling your case because of a borderline serum porcelain.”

Cartwright and Reid forced a laugh for political reasons.

“You don’t understand, Dr. Bellows,” continued Susan. “I’ve never drawn an arterial blood gas. I’ve never seen one drawn.”

Bellows turned from the monitor to Susan. “Jesus Christ, as if I don’t have enough to worry about. It’s just like getting venous blood only you get it out of an artery. What the hell did you learn during the first two years of medical school?”

Susan felt a defensive surge; her face reddened.

“Don’t answer that,” added Bellows quickly. “Cartwright, head over with Susan and…”

“I’ve got that thyroidectomy you put me on with Dr. Jacobs in five minutes,” interrupted Cartwright, looking at his watch.

“Shit,” said Bellows. “OK, Dr. Wheeler, I’ll head over with you and show you how to do an arterial stick but not until things are reasonably quiet here. Things are looking a little better; I’ve got to admit that.” Bellows turned to Reid. “Send up another blood sample for a repeat potassium. Let’s see how we are doing. Maybe we are out of the woods.”

While she was waiting, Susan thought about Bellows’s last comment. He had used the pronoun we rather than saying that Nancy Greenly was out of the woods. It fit the pattern and she pondered about depersonalization. It also reminded her of Stark. He didn’t seem to care for Bellows’s pronouns either.