Robin Cook - Coma

And yet there was something fascinating and academically satisfying seeing the application of the basic scientific knowledge she had acquired. From physiology experiments with animal hearts, she comprehended the disorganization that the fibrillating heart within Nancy Greenly represented. If only the whole mass could be depolarized to stop all electrical activity, then the intrinsic rhythm could possibly begin again.

Susan strained to watch as Bellows placed the defibrillating paddles on Nancy Greenly’s exposed chest. One of the paddles was held directly over the sternum, the other was placed against the left lateral chest, slightly distorting the left breast with its pale nipple.

“Everyone away from the bed!” ordered Bellows. His right thumb made contact and a powerful electric charge spread through Nancy Greenly’s chest, arcing from one paddle to the other. Her body jerked upward; her arms flopped across her chest with her hands twisting inward. The electronic blip disappeared from the screen, then it returned. It traced a relatively normal pattern.

“She’s got a good pulse,” said Cartwright.

Reid held up on the external massage. The rate held steady for several minutes. Then a premature ventricular contraction appeared. The rate was again steady for several minutes followed by three premature ventricular contractions in a row.

“V tach,” said Shergood confidently. “The heart is still very easily excitable. There has to be something very basic wrong here.”

“If you know what it is, don’t keep it from us,” said Bellows. “Meanwhile let’s have some lidocaine, 50 cc.”

One of the nurses drew up the lidocaine and handed it to Bellows. Bellows injected it into the I.V. line. Susan moved so that she could see the monitor screen more clearly.

Despite the lidocaine, the rhythm rapidly deteriorated to senseless fibrillation once more. Bellows swore, Reid started massage, and the nurse recharged the defibrillator.

“What the hell is going on here?” queried Bellows, motioning for another amp of bicarbonate to be given. He didn’t expect an answer; he was posing a purely rhetorical question.

Another dose of epinephrine given I.V., followed by a second defibrillation attempt, returned the rate to a semblance of normal. But premature contractions returned, despite additional lidocaine.

“This has to be the same problem that they had in the OR,” said Bellows, watching the premature contractions increase in frequency until the rhythm dissolved into fibrillation. “You’re up again, Reid ole boy. Let’s go, team.”

By 1:15 Nancy Greenly had been defibrillated twenty-one times. After each shock a relatively normal rhythm would return only to disintegrate into fibrillation after a short duration. At 1:16 the ICU phone rang. It was answered by the ward clerk, who took the information. It was the lab calling with the stat electrolyte values. Everything was normal except the potassium level. It was very low, only 2.8 milliequivalents per liter.

The ward clerk handed the results to one of the nurses, who showed them to Bellows.

“My God! 2.8. How in Christ’s name did that happen? At least we have an answer. OK, let’s get some potassium in her. Put 80 milliequivalents into that I.V. bottle and speed it up to 200 cc per hour.”

Nancy Greenly responded to this command by immediately lapsing back into fibrillation for the twenty-second time. Reid started compression while Bellows readied the paddles. The potassium was added to the I.V.

Susan was totally absorbed by the whole resuscitation procedure. In fact, her concentration had been so great that she had almost missed hearing her name crackle out of the page system speaker near the main desk. The page system had been intermittently active throughout the entire cardiac arrest procedure by calling out the names of physicians followed by an extension number. But the sound had blended and merged with the general background noise, and Susan had been oblivious to it. At least until her own name floated out into the room along with the extension 381.

Somewhat reluctantly Susan left her place by the wall and used the phone at the main desk to answer her page.

381 turned out to be the extension of the recovery room and Susan was quite surprised to be paged from there. She gave her name as Susan Wheeler, not Dr. Susan Wheeler, and said that she had been paged. The clerk told her to hold the line. He returned immediately.

“There’s an arterial blood gas to be drawn on a patient up here.”

“Blood gas?”

“Right. Oxygen, carbon dioxide, and acid levels. And we need it stat.”

“How did you get my name?” asked Susan, twisting the cord on the phone. She hoped it was by some sort of mistake that she had been called.

“I just do as I’m told. Your name is on the chart. Remember it’s stat.” The line went dead. The clerk had hung up before Susan could respond again. Actually she had little else to say. She replaced the receiver and walked back to Nancy Greenly’s bedside. Bellows was repositioning the paddles again. The shock swept through the patient’s body, the arms ineffectually flopping across the chest. It seemed both dramatic and pitiful at the same time. The monitor showed a normal rhythm.

“She’s got a good pulse,” said Cartwright at the groin.

“I think she’s holding her sinus rhythm better now that some of the potassium has gotten into her system,” said Bellows, his eyes glued to the monitor screen.

“Dr. Bellows,” said Susan during the lull in the action. “I got a call to draw an arterial blood gas on a patient in the recovery room.”

“Enjoy yourself,” said Bellows, distracted. He turned to Shergood. “Where in heaven’s name are those medical residents? God, when you need them they lie low. But just try to take someone to surgery and they hang around like a group of vultures, canceling your case because of a borderline serum porcelain.”

Cartwright and Reid forced a laugh for political reasons.

“You don’t understand, Dr. Bellows,” continued Susan. “I’ve never drawn an arterial blood gas. I’ve never seen one drawn.”

Bellows turned from the monitor to Susan. “Jesus Christ, as if I don’t have enough to worry about. It’s just like getting venous blood only you get it out of an artery. What the hell did you learn during the first two years of medical school?”

Susan felt a defensive surge; her face reddened.

“Don’t answer that,” added Bellows quickly. “Cartwright, head over with Susan and…”

“I’ve got that thyroidectomy you put me on with Dr. Jacobs in five minutes,” interrupted Cartwright, looking at his watch.

“Shit,” said Bellows. “OK, Dr. Wheeler, I’ll head over with you and show you how to do an arterial stick but not until things are reasonably quiet here. Things are looking a little better; I’ve got to admit that.” Bellows turned to Reid. “Send up another blood sample for a repeat potassium. Let’s see how we are doing. Maybe we are out of the woods.”

While she was waiting, Susan thought about Bellows’s last comment. He had used the pronoun we rather than saying that Nancy Greenly was out of the woods. It fit the pattern and she pondered about depersonalization. It also reminded her of Stark. He didn’t seem to care for Bellows’s pronouns either.

Monday, February 23, 1:35 P.M.

“Some days are like this,” said Bellows, holding the door open for Susan as they left the ICU. “Lunch can be considered a luxury. Even a nice…” Bellows paused as they walked down the corridor. They were both eyeing the floor. Bellows was searching for a word. Then he changed his incompleted sentence. “On occasion it is even hard to find, time to relieve oneself.”