Robin Cook - Coma

“He must be a little light,” said Dr. Colbert, trying to sort out the layers of tissue in the wound.

“I’ll give him a bit more of this love potion,” said Dr. Goodman. He injected another full cc of Innovar, since the syringe with the Innovar was still connected to the I.V. line. Later he admitted that this could have been a mistake. He should have used only the analgesic, fentanyl. The blood pressure responded rapidly and fell as Berman’s anesthesia deepened again. The blood pressure leveled off at 90/60. The pulse increased to 80 per minute, then fell to a comfortable 72 per minute.

“He’s OK now,” said Dr. Goodman.

“Good. OK, Penny, feed me those chromic sutures and I’ll get this joint closed,” said Colbert.

The resident made fine headway, closing the joint capsule and then the subcutaneous tissues. There was no conversation. Mary Abruzzi sat down in the corner and turned on a small transistor radio. Very faint rock music trickled through the room. Dr. Goodman started the final notations on the anesthesia record.

“Skin sutures,” said Dr. Colbert, straightening up from his crouch over the knee.

There was the familiar slapping sound as the needle holder was thrust into his open hand. Mary Abruzzi changed her worn-out gum for a new stick by lifting the lower part of her mask.

At first it was only one premature ventricular contraction followed by a compensatory pause. Dr. Goodman’s eyes looked up at the monitor. The resident asked for more suture. Dr. Goodman increased the oxygen flow to wash out the nitrous oxide. Then there were two more abnormal ectopic heartbeats and the heart rate increased to about 90 per minute. The change in the audible rhythm caught the attention of the scrub nurse, who looked at Dr. Goodman. Satisfied that he was aware, she went back to supplying the resident with skin sutures, slapping a loaded needle holder in his hand every time he reached up.

Dr. Goodman stopped the oxygen, thinking that maybe the myocardium or heart muscle was particularly sensitive to the high oxygen levels that were obviously in the blood. Later he admitted that this might have been a mistake as welt. He began to use compressed air for aerating Berman’s lungs. Berman was still not breathing on his own.

In quick succession there were several back-to-back runs of the strange premature-type heartbeats, which made Dr. Goodman’s own heart jump in his chest from fright. He knew all too well that such runs of premature ventricular contractions often were the immediate harbinger of cardiac arrest Dr. Goodman’s hands visibly trembled as he inflated the blood pressure cuff. Blood pressure was 80/55; it had fallen for no apparent reason. Dr. Goodman looked up at the monitor as the premature beats began to increase in frequency. The beeping sound became faster and faster, screaming its urgent information into Dr. Goodman’s brain. His eyes swept over the anesthesia machine, the carbon dioxide canister. His mind raced for an answer. He could feel his bowels loosen and he had to clamp down voluntarily with the muscles of his anus. Terror spread through him. Something was wrong. The premature beats were increasing to the point that normal beats were being crowded out as the electronic blip on the monitor began to trace a senseless pattern.

“What the hell’s going on?” yelled Dr. Colbert, looking up from his suturing job.

Dr. Goodman didn’t answer. His trembling hands searched for a syringe. “Lidocaine,” he yelled to the circulating nurse. He tried to pull the plastic cap from the end of the needle but it would not come off. “Christ,” he yelled and flung the syringe against the wall in utter frustration. He tore the cellophane cover from another syringe and managed to get the cap off the needle. Mary Abruzzi tried to hold the lidocaine bottle for him but his trembling hands made it impossible. He snatched the bottle from her and thrust in the needle.

“Holy shit, this guy’s going to arrest,” said Dr. Colbert in disbelief. He was staring at the monitor. The needle holder was still in his right hand; a pair of fine-toothed forceps were in his left hand.

Dr. Goodman filled the syringe with the lidocaine, dropping the bottle in the process so that it shattered on the tile floor. Struggling with his trembling he tried to insert the needle into the I.V. line and succeeded only in jabbing his own index finger, bringing a drop of blood. Glen Campbell whined in the background from the transistor.

Before Dr. Goodman could get the lidocaine into the I.V. line, the monitor abruptly returned to its steady, pre-crisis rhythm. In utter disbelief Dr. Goodman looked at the electronic blip moving through its familiar and normal pattern. Then he grasped the ventilating bag and inflated Berman’s lungs. Blood pressure read 100/60 and the pulse slowed evenly to about seventy per minute. Perspiration coalesced on Dr. Goodman’s forehead and dripped off the bridge of his nose onto the anesthesia record. His own heart rate was over one hundred per minute. Dr. Goodman decided that clinical anesthesia was not always dull.

“What in God’s name was all that about?” asked Dr. Colbert.

“I haven’t the slightest idea,” said Dr. Goodman. “But finish up. I want to wake this guy up.”

“Maybe it’s something wrong with the monitor,” said Mary Abruzzi, trying to be optimistic.

The resident finished the skin sutures. For a few minutes Dr. Goodman had them hold off deflating the tourniquet When they did, the heart rate increased slightly but then returned to normal.

The resident started to cast Berman’s leg. Dr. Goodman continued to aerate the patient while he kept one eye on the monitor. The rate stayed normal. Dr. Goodman tried to record the events on the anesthesia record in between compressions of the ventilating bag. When the cast was completed, Dr. Goodman waited to see if Berman would breathe on his own. There was no breathing effort at all, and Dr. Goodman took over again. He looked at the clock. It was 12:45. He wondered if he should give an antagonist for the fentanyl to try to curtail the respiratory depressant effect it was apparently causing. At the same time he wanted to keep the medication that he gave to Berman to a minimum. His own clammy skin reminded him vividly that Berman was no routine case.

Dr. Goodman wondered if Berman was getting light despite the fact that he was not breathing. He decided to test the lid reflex to find out. There was no response. Instead of stroking the lid, Dr. Goodman lifted the lid and he noted something very strange. Usually the fentanyl; like other strong narcotics, produced very small pupils. Berman’s pupils were enormous. The black area almost filled the clear cornea. Dr. Goodman reached for a penlight and directed the beam into Berman’s eye. A ruby red reflex flashed back but the pupil did not budge.

In total disbelief, Dr. Goodman did it again, then again. He did it once more before his own eyes looked up at nothing. Dr. Goodman said two words out loud… “Good God!”

Monday, February 23, 12:34 P.M.

For Susan Wheeler and the other four medical students, the charge down the hall to the elevator fitted perfectly their preconceptions of the excitement of clinical medicine. There was something horribly dramatic about the headlong rush. Startled patients sitting there casually leafing through old New Yorker magazines while waiting to see their doctors reacted to the stampeding group by drawing their legs and feet more closely to their chairs. They stared at the running figures who clutched at pens, penlights, stethoscopes, and other paraphernalia to keep them from flying from their pockets.

As the group came abreast of, then passed, each patient, the patient’s head swung around to watch the group recede down the corridor. Each assumed that a group of doctors had been called on an emergency, and it was reassuring for the patients to see how earnestly the doctors responded; the Memorial was a great hospital.