Coma

33

Thursday, February 26, 4:23 P.M.

Thirty-six dollars plus tax seemed to Susan an awfully high price for the tasteless room at the Boston Motor Lodge. But at the same time it was worth it. Susan felt refreshed and rested—and safe. She had spent the time during the day rereading her notebook. All the information she had about the OR cases fit the idea of carbon monoxide poisoning. The information about the medical cases fit with the idea of succinylcholine poisoning. But still she had no motive, no rhyme or reason. The cases were too disparate.

Susan made a number of calls to the Memorial to try to learn Walters’s home address, but she was unsuccessful. At one point she had called the Memorial and had Bellows paged, but she hung up before he could answer. Slowly but inexorably, Susan began to comprehend that she was at a dead end. She thought that it was probably time to go to the authorities, tell what she had learned, then take a vacation. She had a month’s vacation coming to her as part of her third year and she was sure that she would be able to get permission to take the time immediately. She’d leave, get away, for get. She thought about Martinique. She liked things French, and she longed for the sun.

The doorman of the motel whistled a cab for her and she got in. She told the driver the address: 1800 South Weymouth Street, South Boston. Then she settled back.

It was stop and go down Cambridge Street, a little better on Storrow Drive, but worse on Berkeley. The cab driver took her through the nicer sections of the South End to avoid traffic. At Mass. Ave. he turned left and the surroundings deteriorated. Once into South Boston, Susan knew she was lost. The housing became monotonous, the streets badly littered. Soon the cab entered an area of warehouses, deserted factories, and dark streets. Nearly every streetlamp had a broken bulb.

When Susan alighted from the cab she found herself in an area that seemed isolated from life. Straight ahead, the only streetlight she could see emitted a beam of light from a modern hooded fixture which illuminated the door of a building, a sign, and the walk leading up to the door. The sign was fabricated in block letters of a deep azure. The sign read: “The Jefferson Institute.” Below the blue letters was a brass plaque. It said: “Constructed with the Support of the Department of Health, Education and Welfare, US Government, 1974.”

The Jefferson Institute was surrounded by an eight-foot-high hurricane fence. The building was set back about fifteen feet from the street. It was a strikingly modern structure surfaced with a white terrazzo conglomerate polished to a high gloss. The walls slanted inward at an angle of eighty degrees, rising in a first story of some twenty-five feet. Then there was a narrow horizontal ledge before the wall soared another twenty-five feet at the same angle. Except for the front entrance, there were no windows or doors along the entire length of the facade on the ground floor. The second story had windows but they were recessed and could not be seen from the street. Only the sharply geometric embrasures were visible and the glow of lights from within.

The building occupied a city block. In a strange way, Susan found it beautiful, though she realized that its effect was enhanced by the surrounding squalor. Susan guessed that it was the centerpiece of some urban renewal scheme. It gave the impression of a two-storey ancient Egyptian mastaba, or the base of an Aztec pyramid.

Susan walked up to the front door. Made of bronzed steel, it had no knobs, no openings of any kind. To the right of the door was a recessed microphone. As Susan stepped onto the Astroturf immediately before the door, she activated a recording which told her to give her name and the purpose of her visit. The voice was deep, reassuring, and measured.

Susan complied, although she hesitated about the purpose of the visit. She was tempted to say tourism, but she changed her mind. She wasn’t feeling very jokey. So, finally, she said, “Academic purposes.”

There was no answer. A rectangular red light beneath the microphone came on. Printed on the glass was the word wait. The light flashed green and the word changed to proceed. Without a sound the bronzed door glided to the right, and Susan stepped over the threshold.

Susan found herself in a stark white hall. There were no windows, no pictures, no decorations at all. The only illumination seemed to be from the floor, which was made of a milky opaque plastic material. Susan found the effect curious and futuristic; she walked ahead.

At the end of the hall, a second silent door glided into the wall, and Susan entered what appeared to be a large, ultramodern waiting room. Its far and near walls were mirrored from floor to ceiling. The two side walls were spotlessly white and totally devoid of any interruptions or decoration. The sameness was somewhat disorienting. As Susan looked at the walls, her eyes began to focus on her own vitreous floaters. She had to blink and make an effort to focus at a distance. Looking into the mirror at the end of the room had the opposite effect Because of the opposing mirrors Susan saw the image of herself reflected to infinity.

The room was furnished with rows of molded white plastic chairs. The floor was the same as in the hall, the light from it casting strange shadows on the ceiling. Susan was about to sit down when another door slid open in the farthest mirrored wall. A tall woman entered and walked directly up to Susan. She had very short, medium brown hair. Her eyes were deeply set and the line of her nose merged imperceptibly with her forehead. Susan was reminded of the classic features of a cameo. The woman wore a white pants suit as devoid of decoration as the walls. A pocket dosimeter peeped from her jacket. Her expression was neutral.

“Welcome to the Jefferson Institute. My name is Michelle. I will show you our facilities.” Her voice was as noncommittal as her expression.

“Thank you,” said Susan, trying to see through the woman’s facade. “My name is Susan Wheeler. I believe you are expecting me.” Susan let her eyes sweep around the room once more. “It certainly is modern. I’ve never seen anything quite like this.”

“We have been expecting you. But before we begin I’d like to warn you that it is very warm inside. I suggest that you leave your coat here. And please leave your bag as well.”

Susan took off her coat, a bit embarrassed by the wrinkled and soiled nurse’s uniform she still had on. She took her notebook from her bag.

“Now then… I suppose that you know that the Jefferson Institute is an intensive-care hospital. In other words, we only take care of chronic intensive-care patients. Most of our patients are in some level of coma. This particular hospital was built as a pilot project with HEW funds, although the actual running of it has been delegated to the private sector. It has been very successful in freeing up beds in the acute intensive care units of the city’s hospitals. In fact, since the project has been so successful, an equivalent hospital is either being built or is in the planning stages in most of the large cities of the country. Research has shown that any city or population center with a population of a million or more can economically support a hospital of this sort…. Excuse me, but why don’t we sit down?” Michelle indicated two of the chairs.

“Thank you,” said Susan, taking one of the chairs.

“Visiting the Jefferson Institute is strictly regulated because of the methodology we use to care for the patients. We have developed very new techniques here, and if people are not prepared, some may react on an emotional level. Only immediate family may visit, and only once every two weeks on a preplanned basis.”

Michelle paused in her monologue, then she managed a half-smile. “I must say that your visit here is highly unusual. Normally we have a group of medical people on the second Tuesday of each month, and there is a planned program for them. But since you have come by yourself, I guess I can improvise a bit. But we do have a short film if you would like to see it.”

“By all means.”

“Good.”

Without any sign from Michelle, the room darkened and on the wall opposite from where they were sitting, a film began to roll. Susan was intrigued. She presumed that the film was being projected through a translucent section of the wall serving as a screen.

The film itself reminded Susan of old newsreels. Its outdated technique seemed an anachronism in the modern surroundings. The first section was devoted to the concept of the intensive care hospital. The Secretary of Health, Education and Welfare was shown discussing the problem with policy planners, economists, and health care specialists. The problem of spiraling hospital costs spearheaded by the cost of long-term intensive care was illustrated by graphs and charts. The men explaining the charts were dull and uninspiring, as commonplace as the suits they wore.

“This is a terrible film,” said Susan.

“I agree. Government films are all alike. You’d think that they’d try a little creativity.”

The movie moved on to ground-breaking ceremonies, at which politicians smiled and joked idiotically. More graphs and charts followed, attesting to the enormous savings that had been accrued by the hospital. There were several more scenes showing how the Jefferson Institute’s facilities freed the beds in the city’s hospitals for the care of acute cases. Then followed a comparison of the number of nurses and other personnel needed at the Jefferson facility to the number needed in a conventional hospital for the same number of intensive care patients. The people used to illustrate this point were photographed milling about aimlessly in a parking lot. Finally, the film showed the heart of the new hospital: the huge computer, both digital and analog. It concluded by pointing out that all the functions of homeostasis were monitored and maintained by the computer. The film ended with a burst of inspirational marching music, like the finale of a war movie. The lights under the floor came on as the last image disappeared.

“I could have done without that,” said Susan, smiling.

“Well, at least it emphasizes the point about the economy. That’s the central concept of the institute. Now, if you’ll follow me, I’ll show you the principal features of the hospital.”

Michelle stood up and walked toward the mirrored wall from which she had appeared. A door glided open. It shut behind them as they entered another corridor about fifty feet long. The far end of the corridor was also mirrored from floor to ceiling. As Susan passed down the hallway she noted other doors but they were all closed. None of the doors had any exposed hardware. Apparently they were automatically activated.

When they reached the far end of the corridor, a door slid open and Susan entered a familiar-looking room. It was about forty by twenty feet and looked exactly like an intensive care unit in any hospital. There were five beds and the usual assortment of gadgets, EKG screens, gas lines, etcetera. But four of the beds appeared different: each was constructed with a gap of some two feet running lengthwise. It was as if each bed were constructed of two very narrow beds with a fixed two-foot span between them. In the ceiling above the beds there were complicated tracklike mechanisms. The fifth bed, which seemed conventional, was occupied. A patient was being breathed by a small respirator. Susan was reminded of Nancy Greenly.

“This is the visiting area for the immediate families,” explained Michelle. “When a family is scheduled to visit, the patient is transferred here automatically. When he is placed in one of these special beds and it is made up, the bed appears like a normal one. This patient was visited this afternoon.” Michelle pointed toward the patient in the fifth bed. “We purposely did not return him to the main ward for your benefit.”

Susan was confused. “You mean that bed the patient is in is the same as these other beds?”

“Exactly. And when family visits, these other beds are filled with other patients so that the area looks like a normal intensive care unit Follow me, please.”

Michelle walked the length of the room, past the patient in the bed. At the end of the room was a door, which opened silently and automatically.

Susan was amazed when she passed the fifth bed with the patient. The bed appeared exactly like a regular hospital bed. There was no evidence that its central section, its basic support, was missing. But Susan had no time to examine the bed more closely as she followed Michelle into the next room.

The first thing Susan became aware of was the light; there was something strange about it. Then she felt the warmth and the humidity. Finally she saw the patients, and she stopped in utter astonishment. There were more than a hundred patients in the room, and all of them were completely suspended in midair about four feet from the floor. All of them were naked. Looking closely, Susan could see the wires piercing multiple points on the patients’ long bones. The wires were connected to complicated metal frames and pulled taut. The patients’ heads were supported by other wires from the ceiling which were attached to screw eyes in the patients’ skulls. Susan had an impression of grotesque, horizontal, sleeping marionettes.

“As you can see, the patients are all suspended by wires under tension. Some visitors react strongly to this, but it has proven to be the best method of long-term care, totally preserving the skin and minimizing nursing care. Its origin was in orthopedics, where wires are passed through bones to provide traction. Burn treatment research showed the benefits to be obtained when the skin does not rest on any kind of surface. It was a natural progression to apply the concept to the care of the comatose patient.”

“It is rather gruesome.” Susan recalled the upsetting image of the cadavers hung in the freezer. “What is the strange lighting?”

“Oh, yes, we should put on glasses if we stay in here much longer.” Michelle fetched several pairs of goggles from a. table.

“There is a low-level of ultraviolet light in here. It has been found useful in controlling bacteria as well as helping to maintain the integrity of the skin.” Michelle offered a set of goggles to Susan, and they both put them on.

“The temperature in here is maintained at ninety-four point five Fahrenheit, plus or minus five hundredths of a degree. The humidity is held at eight-two percent with a one percent variance. That tends to reduce patient heat loss and hence reduces the patients’ caloric needs. The humidity has reduced the respiratory infection problem, which you know is critical for coma patients.”

Susan was spellbound. She gingerly moved closer to one of the suspended patients. A profusion of wires perforated various long bones. The wires then passed horizontally through an aluminum frame around the patient before running up to a complicated trolley device on the ceiling. Susan looked up at the ceiling and saw that it was a maze of tracks for the trolleys. All the I.V. lines, suction tubes, and monitoring lines from the patient ascended to the trolley. Susan looked back at Michelle. “And there are no nurses?”

“I happen to be a nurse, and there are two others on duty, plus one doctor. That’s quite a reasonable ratio for one hundred and thirty-one intensive care patients, wouldn’t you say? You see, everything is automated. The patient’s weight, blood gases, fluid balance, blood pressure, body temperature—in fact, an enormous list of variables—are being constantly scanned and compared to standards by the computer. The computer actuates solenoid valves to rectify any abnormalities or discrepancies it finds. It is far better than conventional care. A doctor tends to concern himself with isolated variables and in a static fashion. The computer is able to sample over time, hence it treats dynamically. But more important still is that the computer correlates all the variables at any given moment. It’s much more like the bodies’ own regulatory mechanisms.”

“Modern medicine carried to the nth degree. It’s incredible, really it is. It’s like some science fiction setting. A machine taking care of a host of mindless people. It’s almost as if these patients aren’t people.”

“They aren’t people.”

“I beg your pardon?” Susan looked up from the patient toward Michelle.

“They were people; now they’re brain stem preparations. Modern medicine and medical-technology have advanced to the point where these organisms can be kept alive, sometimes indefinitely. The result was a cost-effectiveness crisis. The law decided they had to be maintained. Technology had to advance to deal with the problem realistically. And it has. This hospital has the potential to handle up to a thousand such cases at a time.”

There was something about the basic philosophy Michelle elucidated that made Susan uncomfortable. She also had a feeling that her guide had herself been very carefully indoctrinated. Susan could tell that Michelle did not question what she was saying. Nevertheless Susan did not dwell on the institute’s philosophical foundations. She was overwhelmed by the place’s physical aspects. She wanted to see more. She looked around the room. It was more than a hundred feet long, with a fifteen-to twenty-foot ceiling. In the ceiling the maze of tracks was bewildering.

There was another door at the far end of the room. It was closed. But it was a normal door with normal hardware. Susan decided that only the doors they had so far traversed were centrally controlled. After all, most visitors, the families, never came into the main ward.

“How many operating rooms are there here in the Jefferson Institute?” asked Susan suddenly.

“We don’t have operating rooms here. This is a chronic care facility. If a patient needs acute care, he is transferred back to the referring institution.”

The reply was so fast that it gave the impression of a reflex or trained response. Susan distinctly remembered seeing the ORs in the floor plans she had obtained at City Hall. They were on the second floor. Susan began to sense that Michelle was lying.

“No operating rooms?” Susan deliberately acted very surprised. “Where do they do emergency procedures, like tracheotomies?”

“Right here on the main ward or in the ICU visiting room next door. That can be set up as a minor OR if needed. But it rarely happens. As I said, this is a chronic-care hospital.”

“I still would have thought that they would have included an OR.”

At that moment almost directly in front of Susan, one of the patients was automatically tipped back so that his head was about six inches below his feet.’

“There is a good example of the computer working,” said Michelle. “The computer probably sensed a fall in the blood pressure. It put the patient into the Trendelenburg position prior to correcting the main cause for the blood pressure fall.”

Susan was barely listening; she was trying to figure a way to do a little exploring on her own. She wanted to see those operating rooms indicated on the floor plans.

“One of the reasons I asked to come here was to see a particular patient. The name is Berman, Sean Berman. Do you have any idea where he is located?”

“No; not offhand. To tell you the truth, we don’t use names here for the patients. The patients are given numbers, sample 1, sample 2, etcetera. It’s infinitely easier to key into the computer. In order to find Berman’s number, I’ll have to match the name with the computer. It takes a minute or so, that’s all.”

“Well, I would like to find out.”

“I’ll use the information terminal at the control desk. Meanwhile, you could take a look here and see if you can see him. Or you can come with me and wait in the waiting room. No guests are permitted in the control room.”

“I’ll wait here, thank you. There is enough of interest here to keep me occupied for a week.”

“Suit yourself, but, needless to say, don’t touch any of the wires or the patients under any circumstances. The whole system is very carefully balanced. The electrical resistance of your body would be picked up by the computer and an alarm would sound.”

“No need to worry. I’m not about to touch anything.”

“Good. I’ll be right back.”

Michelle removed her goggles. The door to the visiting room opened automatically and she was gone.

Michelle walked through the visitors’ room and halfway down the corridor beyond it. The door to the control room opened for her. It was dimly illuminated like the control room on a nuclear submarine. A good portion of the light in the room came from the far wall, which was actually a two-way mirror permitting observation of the visitors’ hall from the control room.

Two other people occupied the room when Michelle entered. Sitting in front of a large U-shaped bank of TV monitors was a guard. He was also dressed in white, and wore a wide white leather belt, a white-bolstered automatic, and a two-way Sony receiver. He sat in front of a vast console with multiple switches and dials. A battery of TV monitors in front of him was scanning rooms, corridors, and doors throughout the hospital. Several screens had constant images, such as the monitors for the front door and the entry hall. Others changed as remote control video cameras scanned their areas. The guard looked up sleepily as Michelle entered.

“You left her by herself in the ward? Do you think that was wise?”

“She’ll be fine. I was told to let her see what she wanted on the first floor.”

Michelle walked toward a large computer terminal where the other occupant of the room, a nurse dressed like Michelle, sat watching the data displayed on the forty or more screens in front of her. Intermittently the computer’s printer to her right would activate and print out information.

Michelle plopped herself down in a chair.

“Who the hell does she know to get invited here by herself?” asked the computer nurse, suppressing a yawn. “She looks like a Goddamn LPN or something. She doesn’t even have a pin or a cap. And that uniform! It looks like she’s been wearing it for six months.”

“I haven’t the slightest idea who she knows. I got a call from the director saying that she was coming and that we were to let her in and entertain her. I was to call Herr Direktor when she arrived. Do you think there’s some hanky-panky going on?”

The computer nurse laughed.

“Do me a favor,” continued Michelle, “and punch in the name of Sean Berman. He was a Memorial referral. I need his patient number and location.”

The computer nurse began to key in the information. “On our next shift, you can be the computer-sitter while I float. Playing with this machine is starting to drive me up the wall.”

“Gladly. The only break in the routine of floater for the past week has been this visitor. A year ago, if someone told me I would be tending a hundred intensive-care patients myself, I’d have laughed in his face.”

One of the display screens flashed: Berman, Sean. Age 33, sex male, race Caucasian. Diagnosis: cerebral brain death secondary to anesthetic complications. Sample number 323 B4. STOP.

The nurse keyed Sample number 323 B4 back into the computer.

The guard at the other end of the room slouched over, watching the monitors as usual, as he had been doing for two hours since his last break, as he had been doing for almost a year. The picture of the main ward appeared on screen number 15; moving as the video camera slowly panned from one end of the huge room to the other. The dangling nude patients held no interest for the guard. He was finally accustomed to the gruesome scene. Automatically screen number 15 shifted to the intensive-care visitors’ ward as its camera started to scan.

The guard sat up suddenly, looking at the screen of number 15. He reached for the manual mode switch and returned the scan to the main ward. The video camera scanned the enormous room again.

“The visitor is no longer in the main ward!” said the guard.

Michelle turned from the computer display screen and squinted to see screen number 15 of the monitor, “No? Well check the visitors’ ward and the corridor. Maybe she had enough. The main ward is usually a shock for first-time visitors.”

Michelle turned and looked out through the glass to the waiting room, but Susan was not there either.

The display screen on the computer flashed: Sample 323 B4 terminated. 0310 Feb. 26. Cause of death: cardiac arrest. STOP.

“Well if she came here for Berman, she’s too late,” said Karen without feeling,

“She’s not in the visitors’ ward,” said the guard, activating a series of switches. “And she’s not in the corridor. It’s not possible.”

Michelle got up from the chair, her eyes staying on screen 15 until she was at the door. “Calm down. I’ll locate her.” Michelle turned to the nurse at the computer. “Maybe you should try to call the director again. I think we’d better get rid of this girl.”