Robin Cook - Coma

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 mourn 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 me 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 there is no way to bring it back. You can’t do a brain transplant although there are some cases where it might be very useful.” Bellows looked teasingly at Cartwright, who caught the innuendo and laughed.

“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 now 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.”

At that moment the page system came to life as it had been doing intermittently. This time it paged “Dr. Wheeler, Dr. Susan Wheeler, 938 please.” Paul Carpin nudged Susan and informed her about the page. Susan looked up at Bellows quite surprised.

“That was for me?” asked Susan in disbelief. “It said ‘Doctor Wheeler.’ ”

“I gave the nurses on the floor a list of your names to put on the charts in order to divide up the patients among you. You’ll be paged for all the blood work and other fascinating scut.”