Coma

3

Monday, February 23, 9:00 A.M.

Susan Wheeler got a ride in Geoffrey Fairweather’s Jaguar front the dorm to the hospital. It was an older vintage model, an X150, and only three of them could squeeze into it. Paul Carpin was good friends with Fairweather so he was the other lucky one. George Niles and Harvey Goldberg had to bear the brunt of the rush hour Boston MBTA in order to get to the Memorial for the nine o’clock meeting with Mark Bellows.

Once the Jaguar started, which was a minor ordeal typically associated with English motor cars, it covered the four miles in good time. Wheeler, Fairweather and Carpin walked into the main entrance of the Memorial at 8:45. The two others, having expected a miracle of modern transport to carry them the same distance in thirty minutes, arrived at 8:55. It had taken about one hour. The meeting with Bellows was to take place in the lounge of Beard 5 ward. No one knew where the hell they were going. They all trusted to fate to lead them to the proper place as long as they walked into the Memorial itself. Medical students tend to be rather passive, especially after the first two years of sitting in lecture halls daily from nine until five. The two groups met up partly by chance, partly by design, at the main elevators. Wheeler, Fairweather, and Carpin had tried to get to Beard 5 by going up the Thompson Building elevators directly opposite the main entrance. Having been built in haphazard spurts, the Memorial was labyrinthine.

“I’m not sure I’m going to like this place,” said George Niles rather quietly to Susan Wheeler as the group squeezed onto the crowded elevator amid the morning rush. Susan was well aware of the meaning behind Niles’s simple statement. When you don’t want to go somewhere and then have trouble finding it, it’s like adding insult to injury. Besides, all five medical students were in an acute crisis of confidence. They all knew the Memorial was the most renowned teaching hospital and for that reason wanted to be there. But at the same time they felt diametrically opposed to the concept of actually being a doctor, to actually being able to handle some judgmental decision. Their white coats ostensibly associated them with the medical community and yet their ability to handle even the most simple patient-related matter was nonexistent. The stethoscopes which dangled conspicuously from their left side pockets had been used only on each other and a few hand-picked patients. Their memory of the complicated biochemical steps in the degradation of glucose within the cell afforded little support and even less practical information.

Yet they were medical students from one of the best medical schools in the country and that should count for something. They all shared this delusion as the elevator lifted them floor by floor to Beard 5. The doors opened for a doctor in a scrub suit to get out on Beard 2. The five medical students caught a glimpse of the OR holding area in full swing.

Emerging on the fifth floor, the medical students spun on their heels, not sure of which direction to take. Susan took the lead by walking down the corridor to the nurses’ station. Like the OR area below, the nurses’ station on Beard 5 was a beehive of activity. The ward clerk had his right ear glued to the telephone getting A.M. stat blood-work reports. The head nurse, Terry Linquivist, was checking the OR schedule to be sure the pre-op meds had been given to those patients who would be called within the next hour or so. The other six nurses and three LPNs were in all stages of endeavor trying either to get those patients to surgery who had been called or to take care of those patients whose surgery was already part of the past.

Susan Wheeler approached this area of directed activity with an outward show of aplomb, carefully concealing her inner uncertainties. The ward clerk seemed the most accessible.

“Excuse me, but could you tell me…” began Susan.

The ward clerk raised his left hand toward Susan. Tell me that hematocrit again. There’s pandemonium here,” he shouted into the telephone he held between his head and cocked-up shoulder. He wrote on a pad in front of him. “And the patient had a BUN ordered tool” He looked up at Susan, shaking his head about the person he was talking to on the phone. Before she could say anything, his eyes went back to the patient’s chart he had out. “Of course I’m sure a BUN was ordered.” He frantically looked through the chart to find the order sheet. “I filled out the lab request myself.” He checked in the order sheet. “Look, Dr. Needem is going to be bananas if there’s no BUN…. What?… Well if you don’t have enough serum get your ass up here and get some more. The patient is scheduled for eleven. And what about Berman; you got his lab work now? Of course I want it!”

The clerk looked up at Susan, keeping the phone pressed between his ear and his shoulder. “What can I do for you?” he asked Susan rapidly.

“We’re medical students and I wondered if…”

“You’d better talk to Miss Linquivist,” said the clerk suddenly as he looked down at his paper and began madly scribbling figures. He paused long enough to extend his pencil toward Terry Linquivist for Susan’s benefit.

Susan looked over at Terry Linquivist. She noted that the nurse was probably about four or five years her senior. She was attractive in a wholesome sort of way, but definitely overweight according to Susan’s taste. She seemed no less busy than the clerk but Susan was not about to argue. With a quick glance at the rest of her group, who were more than willing to let Susan take the initiative, Susan walked up to Miss Linquivist.

“Excuse me,” said Susan in a polite tone, “we are medical students assigned to…”

“Oh no,” interrupted Terry Linquivist, looking up and then rapidly putting the back of her right hand to her forehead as if she were in the throes of a migraine attack. “Just what I need,” said Linquivist to the wall, carefully emphasizing each word. “On one of the busiest days of the year, I get a new batch of medical students.” She turned to Susan and eyed her with an obvious air of exasperation. “Please don’t bother me now.”

“I don’t intend to bother you at all,” said Susan defensively. “I was just hoping you could tell me where the Beard 5 lounge is.”

“Through those doors opposite the main desk,” said Terry Linquivist, mellowing slightly.

As Susan turned and moved toward her group, Terry Linquivist called out to one of the other nurses. “You’re not going to believe it, Nance, but today is going to be one of those days. Guess what we just got?… We got ourselves a new group of green med students.”

Susan’s ears, sensitized as they were, could pick out a few sighs and groans from the Beard 5 team.

Susan moved around the clerk’s desk. He was still on the phone and still writing. She walked toward the two plain white doors opposite the desk. The others fell in beside her.

“Some welcoming committee,” said Carpin.

“Yeah, real red carpet treatment,” said Fairweather. Despite problems of confidence, medical students still thought of themselves as very important people.

“Ah… a couple of days and the nurses will be eating out of your hand,” said Goldberg smugly. Susan turned and flashed a disdainful glare at Goldberg, who missed it altogether. Goldberg missed most subtle social interpersonal communications. Even some that weren’t very subtle.

Susan pushed through the swinging doors. The room was a jumble of old books, mostly outdated PDR’s (Physician’s Desk Reference), scratch paper, dirty coffee cups, and an assortment of disposable needles and I.V. paraphernalia. There was a counter, desk height, that ran along the length of the wall on the left. A large commercial-type coffee maker was in the middle. At the far end was a curtainless window covered on the outside with Boston grime. Only a meager amount of February morning light penetrated the glass and fell in a pale patch on the aging linoleum floor. The illumination in the room depended entirely on an ample bank of fluorescent lights in the ceiling. The right wall had a bulletin board filled with messages, reminders, and announcements. Next was a blackboard, which had a fine covering of chalk dust In the center of the room was a group of classroom chairs with a small desk piece on each right arm. One of them was pulled in front of the blackboard for Bellows. He was sitting with his yellow legal tablet in front of him. As the medical students filed in, he lifted his left hand and studied his watch. The maneuver was for the benefit of the students, and they recognized the gesture immediately. Especially Goldberg, who was extremely sensitive about nuances which might have an effect on his grade average.

No one said anything for several minutes. Bellows was silent for effect. He’d had no experience with medical students but from his own background he felt obliged to be authoritarian. The medical students were silent because they already felt ill at ease and a bit paranoid.

“It is nine-twenty,” said Bellows eyeing each student in turn. “This meeting was supposed to take place at nine, not nine-twenty.” No one contracted a single facial muscle lest Bellows’s attention be drawn to him. “I think we’d better start out on the right foot,” continued Bellows with authority. He got up laboriously and picked up a piece of chalk. “There’s one thing about surgery, especially here at the Memorial. Things happen on time. You people better take that to heart, or, believe me, your experience here is going to be…” Bellows searched for the proper word while he tapped the chalk on the blackboard. He looked at Susan Wheeler, whose appearance added to his momentary confusion. He glanced out of the window, “…a long cold winter.”

Bellows looked back at the students and began a semiprepared introductory talk. He examined the faces of the students as he talked. He was sure he recognized Fairweather. The very narrow amber-colored horn-rimmed glasses fit into Bellows’s preconception. And Goldberg: Bellows was reasonably confident he could pick him out. The other two males were nondescript entities at that point to Bellows. He hazarded another glance at Susan and felt the same instantaneous confusion. He had not been prepared for the attractiveness of the girl. She was wearing dark blue slacks which seemed to cling disturbingly snugly about her thighs. Above, she had on a lighter blue Oxford cloth shirt, accented by a darker blue and red silk scarf tied around her neck. Her medical student white coat was casually opened. Her ample breasts defiantly advertised her sex, and Bellows was not at all ready to deal with this concept in light of the plans he had formulated for dealing with the students. With some effort he avoided looking at Susan for the time being.

“You’ll be assigned to Beard 5 for only one month of your three month surgical rotation here at the Memorial,” said Bellows, shifting into a familiar monotone associated with medical pedagogy. “In some ways this is an advantage and in others a disadvantage, like so many things in life.”

Carpin chuckled at this feeble attempt at philosophy, but noticing that he was alone, he shut up quickly.

Bellows fixed his gaze on Carpin and continued, “Beard 5 rotation includes the surgical intensive care unit. Hence you will be subjected to an intensive teaching experience. That’s the good part. The disadvantage is that it occurs so early in your clinical exposure. I understand this is your first clinical rotation. Is that correct?”

Carpin looked from side to side to make sure that this last question was directed at him. “We…” His voice faltered, and he cleared his throat. “That’s right,” he managed to say with some difficulty.

“The intensive care unit,” continued Bellows, “is an area where you all have the most to learn, but it represents the most critical area for patient care. All the orders that you write on any patient must be countersigned by myself or one of the two interns on the service, whom you will meet presently. If you write orders in the ICU they have to be countersigned the moment you write them. Orders for patients on the ward can be countersigned en masse at various times during the day. Is that clear?”

Bellows looked at each student, including Susan, who returned his gaze without altering her neutral expression. Susan’s immediate impression of Bellows was not particularly favorable. His manner seemed artificial and his opening mini-lecture on punctuality seemed a little unnecessary so early in the course of events. The monotone of his remarks combined with the pitiful stab at philosophy tended to support the image Susan had begun to construct of the surgical personality from previous conversations and her reading… unstable, egotistical, sensitive to criticism, and above all, dull. Susan did not notice that Mark Bellows was male. Such a thought did not even register in her mind.

“Now,” said Bellows in his artificial monotone, “I’ll have some schedules Xeroxed for you which will outline the basic calendar we’ll follow while you are assigned to Beard 5. The patients on the ward and in the ICU will be divided among you, and you are to work directly with the intern on the case. As for admissions, I want you to set up your own schedule for equitably dividing them. One of you will do a full workup on each admission. As for night call, I want at least one of you to stay here. That means you’ll be on only one in five nights and that’s not overburdening you. In fact, that is less than usual. If others want to stay in the evenings, that’s fine, but at least one of you stays here all night. Get together some time today and give me a schedule of who will be on when.”

“Rounds will begin each morning in the ICU at six-thirty. Before then I want you to have seen your patients, collated all the necessary information to present during the rounds. Is that clear?”

Fairweather looked at Carpin in dismay. He leaned over and whispered in Carpin’s ear, “Christ, I’ll have to get up before I go to bed!”

“Do you have a question, Mr. Fairweather?” demanded Bellows.

“No,” answered Fairweather rapidly. He was intimidated by the fact that Bellows knew his name.

“As for the rest of the morning,” said Bellows, eyeing his watch again. “First I will take you to the ward and introduce you to the nursing staff, who will be thrilled to meet you all, I’m sure,” said Bellows with a wry smile.

“We have experienced their joy already,” said Susan, speaking for the first time. Her voice brought Bellows’s eyes around and held them. “We didn’t expect a brass band for our arrival but at the same time we didn’t expect a cold shoulder.”

Susan’s appearance had already somewhat unnerved Bellows. With the animation that the sound of her voice provided, Bellows’s pulse quickened slightly. There was a certain surge within his body which reminded him of watching cheerleaders in high school and wishing that they were naked. Bellows searched for words.

“Miss Wheeler, you’ll have to understand that the nurses here are primarily interested in one thing.”

Niles winked in agreement to Goldberg, who didn’t understand what Niles was implying.

“And that is patient care, damn good patient care. And when new medical students and/or new interns arrive that becomes a rather difficult goal From actual experience they have all learned that new house staff is probably more deadly than bacteria and virus put together. So don’t expect to be greeted as saviors here, least of all from the nurses.”

Bellows paused but Susan did not respond. She was thinking about Bellows. At least he was a realist and that was a glimmer of hope in the otherwise poor impression he had made on her.

“At any rate, after showing you the ward, we’ll head up to surgery. There’s a staff gallbladder at ten-thirty and it will give you all a chance to get into a scrub suit and see the inside of an OR.”

“And the handle of a retractor,” added Fairweather. For the first time the atmosphere lightened and everyone laughed.

Down in the OR area Dr. David Cowley was absolutely pissed and he spared no one. The circulating nurse had broken into tears before the case was over and had to be replaced. The anesthesiology resident had had to weather one of the worst bombardments of foul words and captious epithets that had ever been hurled over an anesthesia screen. The surgical resident first assisting had a small cut in his right index finger from Cowley’s scalpel.

Cowley was one of the more prosperous of the general surgeons at the Memorial with a spacious private office on Beard 10. He had been spawned, trained, and now nurtured by the Memorial. When things went well, he was a most pleasant chap, full of jokes and ribald stories, always eager to offer an opinion, to bet on a game, to laugh. But when things went contrary to his wishes, he was a firebrand of the most vicious nature, a seething cauldron of invective. In short, he was a juvenile in adult clothing.

His only case that day had gone poorly. To start with, the circulating nurse had put out the wrong surgical instruments. She had set up the Mayo stand with the gallbladder instruments used by the residents. Dr. Cowley had responded by picking up the whole tray and dashing it to the floor. Next the patient quivered a little as he made the initial incision. It was only with great self-discipline that Cowley had curbed his inclination to hurl the scalpel at the anesthesiology resident. Then there was X-ray, who failed to show up at exactly the moment he called. Cowley’s viciousness had so unnerved the poor technician that the first couple of films were totally black.

Somehow Cowley forgot the real reason the case went poorly. Cowley himself had accidentally pulled off the proximal tie on the artery to the gallbladder, causing the wound to fill up with Mood in seconds. It had been a struggle to re-isolate the vessel and get a tie around it without disturbing the integrity of the hepatic artery. Even after the bleeding had been controlled, Cowley still was not positive that he had not compromised the blood supply to the liver.

Coming into the deserted doctors’ lounge, Cowley was raging. He was mumbling inaudibly as he passed down the row of lockers to his own. With emphasis he flung his scrub hat and mask onto the floor. Then he kicked his locker with jarring force.

“Fucking incompetent assholes. This Goddamned place is going to the dogs.”

The fury of his kick followed by an overhead fist which he brought against the door of the locker did several things. First, it raised a cloud of previously undisturbed dust which had settled on top of the locker over some five years. Second, it dislodged a single scrub shoe, which fell, just missing Cowley’s head. Third, it jarred open the locker next to Cowley’s, causing some of the contents to spill out onto the floor.

Cowley dealt with the shoe first He threw it as hard as he could against the far wall. Then he kicked open the locker next to hit in preparation to replace the objects which had fallen out. One glance into the locker, however, made him pause.

Looking closer, Cowley was astonished to see that the locker contained an enormous collection of medications. Many were open, half-used containers and vials, but there were also many unopened. There were ampules, bottles, and pills in a bewildering assortment. Of the drugs that had fallen out, Cowley noted Demerol, succinylcholine, Innovar, Barocca-C, and curare. Within the locker were many more varieties, including an entire carton of unopened morphine bottles, syringes, plastic tubing, and tape.

Quickly Cowley replaced the medicines that had fallen to the floor. Then he locked the locker once again, In his calendar book he wrote the number 338. Cowley was going to check on that locker and see to whom it was assigned. Despite his anger, he had the presence of mind to realize that such a cache was important and had serious implications for the entire hospital. And with things that bothered him, Cowley had the memory of a sage.