Coma

11

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 hand 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 loose-leaf 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 counter top. 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 counter top 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 makes 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.

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.

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 an ovulatory 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.

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 pa® was another note from Dr. 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 had Nancy Greenly 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.