Coma by Robin Cook
The group moved en masse into the ICU. As the oversized ICU door closed, the outside world faded and disappeared. A surrealistic alien environment emerged out of the gloom as the students’ eyes adjusted to the lower level of illumination. The usual sounds like voices and footsteps were muted by the sound-absorbing baffling in the ceiling. Mechanical and electronic noises dominated, particularly the rhythmical beep of the cardiac monitors and the to-and-fro hiss of the respirators. The patients were in separate alcoves, in high beds with the side rails pulled up. There was the usual profusion of intravenous bottles and lines hanging above them, connected to impaled blood vessels by sharp needles. Some of the patients were lost in layer upon layer of mummylike bandages. A few of the patients were awake and their darting eyes betrayed their fear and the fine line that divided them from acute insanity.
Susan surveyed the room. Her eyes caught the fluorescent blips racing across the front of the oscilloscope screens. She realized how little information she could garner from the instruments in her present state of ignorance. And the I.V. bottles themselves with their complicated labels signifying the ionic content of the contained fluid. In an instant, Susan and the other students felt the sickening feeling of incompetence; it was as if the entire first two years of medical school had meant nothing.
Feeling a modicum of safety in numbers, the five students moved even closer together and walked in unison to one of the center desks. They were following Bellows like a group of puppies.
“Mark,” called one of the ICU nurses. Her name was June Shergood. She had thick luxurious blonde hair and intelligent eyes that looked through rather thick glasses. She definitely was attractive and Susan’s keen eye could detect a certain change in Bellows’s demeanor. “Wilson has been having a few runs of PVCs, and I told Daniel that we should hang a lidocaine drip.” She walked over to the desk. “But good old Daniel couldn’t seem to make up his mind, or . . . something.” She extended an EKG tracing in front of Bellows. “Just look at these PVCs.”
Bellows looked down at the tracing.
“No, not there, you ninny,” continued Miss Shergood, “those are his usual PVCs. Here, right here.” She pointed for Bellows and then looked up at him expectantly.
“Looks like he needs a lidocaine drip,” said Bellows with a smile.
“You bet your ass,” returned Shergood. “I mixed it up so I could give about 2 mg per minute in 500 D5W. Actually it’s all hooked up and I’ll run over and start it. And when you write the order include the fact that I gave him a bolus of 50 mg when I first saw the runs of PVCs. Also maybe you should say something to Cartwright. I mean, this is about the fourth time he couldn’t make up his mind about a simple order. I don’t want any codes in here we can avoid.”
Miss Shergood bounced over to one of the patients before Bellows could respond to her comments. Deftly and with assurance she sorted out the twisted I.V. lines to determine which line came from which bottle. She started the lidocaine drip, timing the rate of the drops falling into the plastic chamber below the bottle. This rapid exchange between the nurse and Bellows did little to buoy the already nonexistent confidence of the students. The obvious competence of the nurse made them feel even less capable. It also surprised them. The directness and seeming aggressiveness of the nurse was a far cry from their rather traditional concept of the professional nurse-physician relationship under which they all still labored.
Bellows pulled out a large hospital chart from the rack and placed it on the desk. Then he sat down. Susan noticed the name on the chart. N. Greenly. The students crowded around Bellows.
“One of the most important aspects of surgical care, any patient care really, is fluid balance,” said Bellows, opening the chart, “and this is a good case to prove the point.”
The door to the ICU swung open, allowing a bit of light and hospital sounds to spill into the room. With it came Daniel Cartwright, one of the interns on Beard 5. He was a small man, about five seven. His white outfit was rumpled and blood-spattered. He sported a moustache but his beard was not very thick and each hair was individually discernible from its origin to its tip. On the crown of his head he was going bald rather rapidly. Cartwright was a friendly sort and he came up to the group directly.
“Hi, Mark,” said Cartwright making a gesture of greeting with his left hand. “We finished early on the gastrectomy so I thought I’d tag along with you if I may.”
Bellows introduced Cartwright to the group and then asked him to give a capsule summary on Nancy Greenly.
“Nancy Greenly,” began Cartwright in a mechanical fashion, “twenty-three-year-old female, entered the Memorial approximately one week ago for a D&C. Past medical history entirely benign and noncontributory. Routine pre-op workup normal, including negative pregnancy test. During surgery she suffered an anesthetic complication and she has been comatose and unresponsive since that time. EEG two days ago was essentially flat. Current status is stable: weight holding; urine output good; BP, pulse, electrolytes, etcetera, all OK. There was a slight temperature elevation yesterday afternoon but breath sounds are normal. All in all, she seems to be holding her own.”
“Holding her own with a good deal of help from us,” corrected Bellows.
“Twenty-three?” asked Susan suddenly while glancing around at the alcoves. Her face reflected a tinge of anxiety. The soft light of the ICU hid this from the others. Susan Wheeler was twenty-three years old.
“Twenty-three or twenty-four, that doesn’t make much difference,” said Bellows as he tried to think of the best way to present the fluid balance problem.
It made a difference to Susan.
“Where is she,” asked Susan, not sure if she really wanted to be told.
“In the corner on the left,” said Bellows without looking up from the input-output sheet in the chart. “What we need to check is the exact amount of fluid the patient has put out versus the exact amount that has been given. Of course this is static data and we are more interested in the dynamic state. But we can get a pretty good idea. Now let’s see, she put out 1650 cc of urine . . .”
Susan was not listening at this point. Her eyes fought to discern the motionless figure in the bed in the corner. From where she was standing, she could make out only a blotch of dark hair, a pale face, and a tube issuing from the area of the mouth. The tube was connected to a large square machine next to the bed that hissed to and fro, breathing for the patient. The patient’s body was covered by a white sheet; the arms were uncovered and positioned at forty-five-degree angles from the torso. An I.V. line ran into the left arm. Another I.V. line ran into the right side of her neck. Heightening the somber effect, a small spotlight directed its concentrated beam down from the ceiling above the patient, splashing over the head and upper body. The rest of the corner was lost in shadow. There was no motion, no sign of life save for the rhythmical hiss of the breathing machine. A plastic line curled down from under the patient and was connected to a calibrated urine container.
“We also have to have an accurate daily weight,” continued Bellows.
But for Susan his voice drifted in and out of her awareness. “A twenty-three-year-old woman . . .” The thought reverberated in Susan’s mind. Without the aid of an extensive clinical experience, Susan was instantly lost in the human element. The age and sex similarity struck too close to home for her to avoid the identification. In a naive way she associated such serious medicine with old people who had had their fling at life.
“How long has she been unresponsive,” asked Susan absently, without taking her eyes from the patient in the corner, without even blinking.
Bellows, interrupted by this non sequitur, turned his head up to glance at Susan. He was insensitive to Susan’s state of mind. “Eight days,” said Bellows, slightly vexed at the interruption of his harangue about fluid balance. “But that has little to do with today’s sodium level, Miss Wheeler. Could you kindly keep your mind on the subject at hand.”
Bellows shifted his attention to the
Susan continued to stare at the motionless individual in the corner, racing through a mental checklist of her friends who had had D&Cs, wondering what really divided herself or her friends from the plight of Nancy Greenly. Several minutes passed as she bit her lower lip, as was her custom when in deep thought.
“How’d it happen?” asked Susan, again unexpectedly.
Bellows’s head popped up for the second time, but more rapidly, as if he expected some imminent catastrophe. “How’d what happen?” he countered, scanning the room for some telltale activity.
“How’d the patient become comatose?”
Bellows sat up straight, closed his eyes and put his pencil down. As if counting to ten, he paused before speaking.
“Miss Wheeler, you’ve got to try to give me a hand,” said Bellows slowly and condescendingly. “You’ve got to stay with us. As for the patient, it was just one of those inexplicable twists of the fickle finger of fate. OK? Perfect health . . . routine D&C . . . anesthesia and induction without a ripple. She just never woke up. Some sort of cerebral hypoxia. The squash didn’t get the oxygen it needed. OK? Now let’s get back to work. We’ll be here all day getting these orders written and we’ve got Grand Rounds at noon.”
“Does that kind of complication occur often?” persisted Susan.
“No,” said Bellows, “rare as hell, maybe one in a hundred thousand.”
“One hundred percent for her, though,” added Susan with an edge on the tips of her words.
Bellows looked up at Susan without any idea of what she was driving at. The human element in Nancy Greenly’s case had ceased to be a part of his concern. Bellows was intent on keeping the ions at the right level, keeping the urine output up, and keeping the bacteria at bay. He did not want Nancy Greenly to die while she was on his service because if she did, it would reflect on the kind of care he was capable of providing, and Stark would have some choice comments for him. He remembered all too well what Stark had said to Johnston after a similar case had resulted in death while Johnston was on the service.
It wasn’t that Bellows didn’t care about the human element, it was just that he didn’t have time for it. Besides the sheer number of cases he had been and was involved with provided a cushion or a numbness associated with anything done repeatedly. Bellows did not make the association between Susan’s and Nancy Greenly’s ages, nor did he remember the emotional susceptibility associated with an individual’s initial clinical experiences in the hospital environment.
“Now for the hundredth time, let’s get back to work,” said Bellows, pulling his chair in closer to the desk and running his hand nervously through his hair. He looked at his watch before going back to his calculations. “OK, if we use 1/4 normal saline, let’s see how many milliequivalents we’ll get in 2500 cc.”
Susan was totally detached from the conversation, almost in a fugue. Following some inner curiosity, she moved around the desk and approached Nancy Greenly. She moved slowly, warily, as if she were approaching something dangerous, and absorbing all the details of the scene as they came available. Nancy Greenly’s eyes were only half closed and the lower edges of her blue irises were visible. Her face was a marble white, which contrasted sharply with the sable brown of her hair. Her lips were dried and cracked, her mouth held open with a plastic mouthpiece so she wouldn’t bite the endotracheal tube. Brownish material had crusted and hardened on her front teeth; it was old blood.
Feeling slightly giddy, Susan looked away for a moment and then back. The harshness of the image of the previously normal young woman made her tremble with undirected emotion. It wasn’t sadness per se. It was another kind of inner pain, a sense of mortality, a sense of the meaningless of life which could be so easily disrupted, a sense of hopelessness, and a sense of helplessness. All these thoughts cascaded into the center of Susan’s mind, bringing unaccustomed moisture to the palms of her hands.
As if reaching for a delicate piece of porcelain, Susan lifted one of Nancy Greenly’s hands. It was surprisingly cold and totally limp. Was she alive or dead? The thought crossed Susan’s mind. But there directly above was the cardiac monitor with its reassuring electronic blip tracing excitedly its pattern.
“I shall assume you are a whiz at fluid balance, Miss Wheeler,” said Bellows at Susan’s side. His voice broke the semitrance Susan had assumed and she replaced carefully Nancy Greenly’s hand. To Susan’s surprise the whole group had moved over to the bedside.
“This, everybody, is the CVP line, the central venous pressure,” said Bellows holding up the plastic tube whose tip snaked into Nancy Greenly’s neck. “We just keep that open for now. The I.V. goes in the other side, and that’s where we’ll hang our 1/4 normal saline with the 25 milliequivalents of potassium to run at 125 cc per hour.”
“Now then,” continued Bellows after a slight pause, obviously thinking while looking vacantly at Nancy Greenly, “Cartwright, be sure to order electrolytes on her urine today but leave the standing order for daily serum electrolytes. Oh yeah, include magnesium levels too, OK?”
Cartwright was madly writing these orders down on the index card he had for Nancy Greenly. Bellows took his reflex hammer and absently tried for deep tendon reflexes on Nancy Greenly’s legs. There were none.
“Why didn’t you do a tracheostomy?” asked Fairweather.
Bellows looked up at Fairweather and paused. “That’s a very good question, Mr. Fairweather.” Bellows turned to Cartwright, “Why didn’t we do a tracheostomy, Daniel?”
Cartwright looked from the patient to Bellows, then back to the patient. He became visibly flustered and consulted his index card despite the fact that he knew the information was not there.
Bellows looked back at Fairweather. “That’s a very good question, Mr. Fairweather. And if I remember correctly I did tell Dr. Cartwright to get the ENT boys over here to do a trach. Isn’t that right, Dr. Cartwright?”
“Yeah, that’s right,” enjoined Cartwright. “I put in the call but they never called back.”
“And you never followed up on it,” added Bellows with uncamouflaged irritation.
“No, I got involved . . . ,” began Cartwright.
“Cut the bullshit, Dr. Cartwright,” interrupted Bellows. “Just get the ENT boys up here stat. It doesn’t look like this one is going to come to, and for long-term respiratory care we need a trach. You see, Mr. Fairweather, the cuffed endotracheal tube will eventually cause necrosis of the walls of the trachea. It is a good point.”
Harvey Goldberg fidgeted, wishing he had asked Fairweather’s question.
Susan revived from the depths of her daydream as a result of the verbal exchange between Bellows and Cartwright.
“Does anybody have any idea why this horrible thing has happened to this patient?” asked Susan.
“What horrible thing?” asked Bellows nervously while he mentally checked the I.V., the respirator, and the monitor. “Oh, you mean the fact that she never woke up. Well . . .” Bellows paused. “That reminds me. Cartwright, while you’re calling consults, have neurology get their asses up here and do another EEG on this patient. If it is still flat, maybe we can get the kidneys.”
“Kidneys?” questioned Susan with horror, trying not to think about what such a statement meant for Nancy Greenly.
“Look,” said Bellows putting his hands on the railing with his arms extended. “If her squash is gone, I mean wiped out, then we might as well get the kidneys for someone else, provided of course, we can talk the family into it.”
“But she might wake up,” protested Susan with color rising in her cheeks, her eyes flashing.
“Some of them wake up,” shrugged Bellows, “but most don’t when they have a flat EEG. Let’s face it; it means the brain is infarcted, dead, and t
“Doesn’t anyone know why this patient’s brain didn’t get the oxygen it needed during surgery?” asked Susan, going back to her previous question in a desperate attempt to avoid even the thought of taking the kidneys out of Nancy Greenly.
“No,” said Bellows plainly and looking directly at Susan. “It was a clean case. They’ve gone over every inch of the anesthesia procedure. It happened to be one of the most compulsive of all the anesthesiology residents and he’s sucked the case dry. I mean, he’s been merciless on himself. But there’s been no explanation. It could have been some sort of stroke, I guess. Maybe she had some condition which made her susceptible to having a stroke. I don’t know. In any case, oxygen was apparently kept from the brain long enough so that too many of the brain cells died. It so happens that the cells of the cerebrum are very sensitive to low levels of oxygen. So they die first when the oxygen falls below a critical level and the result is what we have here”—Bellows made a gesture with his hand, palm up, over Nancy Greenly—“a vegetable. The heart beats because it doesn’t depend on the brain. But everything else must be done for the patient. We have to breathe her with the respirator there.” Bellows motioned toward the hissing machine to the right of Nancy’s head. “We have to maintain the critical balance of fluids and electrolytes as we were doing a few moments ago. We have to feed her, regulate the temperature . . .” Bellows paused after he said the word temperature. The concept keyed off his memory. “Cartwright, order a portable chest X-ray today. I almost forgot about the temp elevation you mentioned a little while ago.” Bellows looked at Susan. “That’s how most of these brainstem patients depart from this life, pneumonia . . . their only friend. Sometimes I wonder what the shit I’m doing when I treat the pneumonia. But in medicine we don’t ask questions like that. We treat the pneumonia because we have the antibiotics.”