Coma by Robin Cook
“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 blood in seconds. It had been a struggle to reisolate 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 his 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.
Monday
February 23
10:15 A.M.
Susan Wheeler could not go into the doctors’ lounge to change into a scrub suit because the doctors’ lounge was synonymous with the men’s lounge. Susan had to go into the nurses’ locker room, which was synonymous with women’s lounge. So creeps society from day to day, thought Susan angrily. To her it was just another blatant example of male chauvinism and it gave her a momentary lift to think that she was upsetting this unfair identification. The locker room was at that moment deserted and Susan located an empty locker with ease and began to change by hanging up her white coat. Nearby the shower entrance she found the scrub suits. They were one-piece pale blue dresses made from plain cotton fabric. They were actually for the scrub nurses. She held it up and then against herself. Looking into the mirror, she felt suddenly rebellious despite the intimidating surroundings.
“Screw the dress,” said Susan to the mirror. The scrub dress arched in a tumble into the canvas hamper while Susan retraced her steps into the hall. She paused before the doctors’ lounge, and she almost lost her nerve. Impulsively she pushed open the door.
Bellows was at that very instant next to the door that Susan opened. He was reaching into one of the cabinets at the entrance for a scrub suit. He was clothed in his James Bond-style skivvies (that’s what he called them) and black socks. He looked as if he belonged in the beginning of a grade C porno movie. Horror spread across his face as he caught sight of Susan. In a flash, he fled into the safety of the depths of the dressing room. As in the nurses’ locker room, one could not see into the dressing room from the door. Spurred by her rebelliousness despite the unexpected encounter, Susan advanced to the cabinet and selected a small scrub top and pants; then she left as quickly as she had entered. She could hear a tangle of excited voices in the interior of the doctors’ lounge.
Back in the nurses’ locker room, she completed changing rapidly. The pale green shirt was too large, as were the pants. Because of her narrow waist she had to cinch up the pants to their absolute maximum before tying the cord. Mentally she began to prepare for the inevitable diatribe from Bellows, the mighty surgeon-to-be, by deciding how she would counter. During their brief introductions on the ward, Susan had been very aware of the condescending attitude Bellows had directed toward the nurses. This attitude was ironical coming so soon after the commendable defense of the nurses he had made to explain their lack of enthusiasm toward new medical students. It was pretty obvious to Susan that Bellows was, among other things, a typical chauvinist. Susan decided that she would challenge that aspect of Bellows’s personality. Maybe it would make the surgical rotation at the Memorial a bit more bearable. Of course she had not planned to see Bellows in his underwear in the dressing room, but the image and symbolic aspects made Susan laugh out loud before she passed through the door into the OR area.
“Miss Wheeler, I presume,” said Bellows as Susan emerged. Bellows was leaning casually against the wall to the left of the doorway, obviously waiting for Susan to appear. His right elbow was on the wall, with the hand supporting his head. Susan literally jumped at the sound of his voice since she hardly expected him to be waiting there for her.
“I must admit,” continued Bellows, “you really caught me with my pants down.” A broad smile spread across his face, changing him in Susan’s eyes to a rather human individual. “That was one of the funniest things that has happened to me in a long time.”
Susan smiled in return but it was a half-smile. She was expecting the tirade to commence immediately.
“After I recovered and realized what you were after,” continued Bellows, “I started to think that it was a pretty ridiculous response on my part to bolt. If I had had any sense I would have stood there and faced you despite my dress . . . or the lack of it. At any rate, it made me think that I might have been relying on appearances a bit too much this morning. I’m a second-year resident, that’s all. You and your friends are my first group of students. What I really want to do is to make this time here as profitable as possible for you all, and in the process, profitable for me as well. Last o
With a final smile and slight nod of the head, Bellows walked away from the stunned Susan to check which room the staff gallbladder was in. It was Susan’s turn to feel a sense of confusion as she looked after him. The resolve her feelings of anger and rebelliousness had evoked had been undermined by Bellows’s sudden insight into himself. In fact it made her rebelliousness seem a trifle foolish and out of place. The fact that Susan had stimulated the insight fortuitously made it obvious that she couldn’t take credit for it and that she would have to revise some of her impressions about Mark Bellows. She watched Bellows walk all the way over to the main OR desk; he was obviously at home in the alien environment. For the first time Susan was a little impressed. In fact, she thought that he really wasn’t that bad looking either.
The others were already prepared to go down to the OR. George Niles showed Susan how to put on the paper booties over her shoes and tuck in the conductive tape. Next she put on the hood and finally the mask. Once everyone was so attired, they passed the main OR desk and pushed through the swinging doors into the “clean” area of the ORs themselves.
Susan had never been in an OR before. She had seen a couple of operations through the gallery windows but such an experience was akin to watching it on TV. The glass partition effectively isolated the drama. One did not feel a part of it. While walking down the long corridor Susan felt a certain excitement mixed with fear of the mortality of people. As they passed OR after OR, Susan could see clusters of figures bent over what she knew were sleeping patients with their fragile insides open to the elements. A hospital gurney approached them with a scrub nurse pulling and an anesthesiologist pushing. As the group came abreast Susan could see that the anesthesiologist was matter-of-factly holding the patient’s chin back while the patient retched violently. “I hear there’s almost forty inches of packed powder at Waterville Valley,” said the anesthesiologist to the scrub nurse. “I’m going Friday right after work,” returned the scrub nurse as the pair passed by Susan toward the recovery room. The image of the tortured face of the patient so recently operated on imprinted itself in Susan’s susceptible consciousness and she shuddered involuntarily.
The group pulled up in front of room 18.
“Try to keep the chatter to a minimum,” said Bellows, looking through the window in the door. “The patient is already asleep. Too bad, I wanted you to see that. Well, no matter. There will be a lot of moving around during the draping procedure, etcetera, so stay back against the right wall. Once they get under way, move around so that you can see something. If you have questions, save them until later, OK?” Bellows looked at each student. He smiled anew when he met Susan’s gaze, then pushed open the OR door.
“Ah, Professor Bellows, welcome,” boomed a large, gowned, gloved, and sterile figure hovering in the background near some X-rays. “Professor Bellows has brought his brood of students to watch the fastest hands in the East,” he said laughing. He held up his arms in an exaggerated Hollywood surgical fashion with the hands up and bent outward as far as they would go. “I hope you have told the impressionable youths that the spectacle they are about to see is a rare treat.”
“That hulk,” said Bellows to the students while motioning toward the laughing character by the X-rays and loud enough for all in the OR to hear, “is the result of staying in the program too long. That’s Stuart Johnston, one of the three senior residents. We only have to put up with him for four more months. He had promised me he’d be civil, but I cannot be sure of that.”
“You’re just a poor sport, Bellows, because I stole this case from you,” said Johnston, still laughing. Then to his two assistants he said without laughing, “Let’s get the patient draped, you guys. What are you trying to do, make this your life’s work?”
The draping proceeded rapidly. A small piece of tubular metal arched over the top of the patient’s head and separated the anesthesiologist from the surgical area. By the time the draping was completed, only a small portion of the patient’s right upper abdomen was exposed. Johnston moved to the patient’s right side; one of the assistants went over to the left side. The scrub nurse moved over the draped Mayo stand, straining with a full complement of surgical instruments. A profusion of hemostats was lined up in a perfect array along the back of the tray. The scalpel had a new razor-sharp blade snapped into its jaws.
“Knife,” said Johnston. The scalpel slapped into his gloved right hand. With his left hand he pulled the abdominal skin away from him to provide countertraction. The medical students all moved forward silently and strained to see with a foreboding curiosity. It was like watching an execution. Their minds tried to prepare themselves for the image that was going to be imminently transmitted to their brains.
Johnston held the scalpel about two inches above the pale skin while he looked over the screen at the anesthesiologist. The anesthesiologist was slowly letting the air out of the blood pressure cuff and watching the gauge. 120/80. He looked up at Johnston and gave an imperceptible nod, tripping the poised guillotine. The scalpel dived deep into the tissues, and then with a smooth soundless slice, slid down the skin at an angle of approximately 45 degrees. The wound fell open and little jets of pulsating arterial blood sprayed the area, then ebbed and died.
Meanwhile curious phenomena occurred in George Niles’s brain. The image of the knife plunging into the skin of the patient was displayed instantly in his occipital cortex. Association fibers picked up the message and transported the information to his parietal lobe, where it was associated. The association spread so rapidly and so widely that it activated an area of his hypothalamus, causing widespread dilation of his blood vessels in his muscles. The blood literally drained from his brain to fill all the dilated vessels, causing George Niles to lose consciousness. In a dead faint he fell straight backward. His flaccid neck snapped his head against the vinyl floor with a resonant thump.
Johnston spun around in response to the sound of George’s head smashing against the floor. His surprise quickly metamorphosed into typically labile surgical anger.
“For Christ’s sake, Bellows, get these kids outa here until they can stand the sight of a few red cells.” Shaking his head, he went back to catching bleeders with his hemostats.
The circulating nurse broke a capsule under George’s nose and the acrid smell of the ammonia shocked him back to consciousness. Bellows bent down and felt along his neck and the back of his head. As soon as George was fully conscious, he sat up, somewhat confused about his whereabouts. Realizing what had happened, he felt immediately embarrassed.
Johnston meanwhile wouldn’t let the matter rest.
“Holy shit, Bellows, why didn’t you tell me these students were absolute greenhorns? I mean, what would have happened if the kid fell into my wound here?”
Bellows didn’t say anything. He helped George to his feet by degrees until he was satisfied George was really OK. Then he motioned for the group to leave OR No. 18.
Just before the OR door shut, Johnston could be heard angrily yelling at one of his junior residents, “Are you here to help me or hinder me . . . ?”
Monday
February 23
11:15 A.M.
George Niles’s pride was hurt more than anything else. He developed a rather sizable lump on the back of his head but there was no laceration. His pupils stayed equal in size and his memory was unimpaired. Consensus had it that he was going to make it. However, the episode dampened the spirits of the whole group. Bellows was nervous that the fainting would reflect on his judgment to bring the students into the OR on the first day. George Niles was concerned lest the incident foreshadowed similar responses every time he tried to watch a surgical case. The others were bothered to a greater or lesser degree simply because within a group, the actions of one individual tend to reflect the whole group’s performance. Actually Susan was not concerned with this aspect as were the others. Susan was more distressed about the sudden and unexpected response and change in attitu
After changing back to their street clothes, they all had a cup of coffee in the surgical lounge. It was surprisingly good coffee, thought Susan, trying to overcome the oppressive haze of cigarette smoke which hung like Los Angeles smog from the ceiling to a level about five feet from the floor. Susan was mindless of the people in the lounge until her eyes met the stare of a pasty white-skinned man hovering in the corner near the sink. It was Walters. Susan looked away and then back again, thinking that the man was not really watching her. But he was. His beady eyes burned through the cigarette haze. Walters’s omnipresent cigarette hung by some partially dried saliva holding the extreme tip in the corner of his lips. A trail of smoke snaked upward from the ash. For some unknown reason he reminded Susan of the hunchback of Notre Dame, only without a hunchback: a ghoulish figure out of place yet obviously at home in the shadows of the Memorial surgical area. Susan tried to look away but her eyes were involuntarily drawn toward the uncomfortable stare of Walters. Susan was glad when Bellows motioned to leave and they drained their cups. The exit was near to the sink, and as the group left the room, Susan had the feeling she was walking down Walters’s line of vision. Walters coughed and the phlegm rattled. “Terrible day, eh, Miss,” said Walters as Susan passed.
Susan didn’t respond. She was glad to be rid of the staring eyes. It had added to her nascent dislike of the surgical environment of the Memorial.