Robin Cook - Coma

And what about himself? Could Bellows handle a sharp girl who was in his own field even if she were warm and lovable? He had dated a few nurses, but that was different because nurses were allied with but distinct from doctors. Bellows had never dated another doctor or even doctor-to-be. Somehow the idea was a bit disturbing.

Leaving the cafeteria, Susan enjoyed a greater sense of direction than she had felt all day. Although she had no idea how she was actually going to investigate the problem of prolonged coma after anesthesia, she felt that it represented an intellectual challenge which could be met by applying scientific methods and reasoning. For the first time all day she had a feeling that the first two years of medical school had meant something. Her sources were to be the literature in the library and the charts of the patients, particularly Greenly’s and Berman’s.

Near to the cafeteria was the hospital gift shop. It was a pleasant place, populated and run by an assortment of gracefully aging’ suburbanite women dressed in cute pink smocks. The windows of the shop faced the main hospital corridor and were mullioned, giving the shop an appearance of a cottage smack dab in the middle of the busy hospital. Susan entered the gift shop and quickly found what she was after: a small black loose-leaf notebook. She slipped the purchase into her pocket of her white coat and left for the ICU. Her jumping-off point would be the case of Nancy Greenly.

The ICU was back to its pre-arrest hush. The harsh illumination had been dampened to the level Susan recalled from her first visit. The instant the heavy door closed behind her, Susan tasted the same anxiety she had noted before, the same feeling of incompetence. Again she wanted to leave before something happened and she was asked the simplest of questions to which she would undoubtedly have to answer a demoralizing “I don’t know.” But she did not bolt. Now she at least had something to do which gave her a modicum of confidence. She wanted the chart of Nancy Greenly.

Looking to the left, Susan noticed that no one was standing by Nancy Greenly’s bed. The potassium level had apparently been rectified and the heart was beating normally once again. The crisis over, Nancy Greenly was forgotten and allowed to return to her own infinity. Willing machines resumed the vigil over her vegetablelike functions.

Drawn by an irresistible curiosity, Susan walked over to Nancy Greenly’s side. She had to struggle to keep her emotions in check and to keep the identification transference to a minimum. Looking down at Nancy Greenly, it was difficult for Susan to comprehend that she was looking at a brainless shell rather than a sleeping human being. She wanted to reach out and gently shake Nancy’s shoulder so that she would awaken so that they could talk.

Instead, Susan reached out and picked up Nancy’s wrist. Susan noted the delicate pallor of the hand as it drooped, lifelessly. Nancy was totally paralyzed, completely limp. Susan began to think about paralysis from destruction of the brain. The reflex circuits from the periphery would still be intact, at least to some degree.

Susan grasped Nancy’s hand as if she were shaking it and slowly flexed and extended the wrist. There was no resistance. Then Susan flexed the wrist forcefully to its limit, the fingers almost touching the forearm. Unmistakenly Susan felt resistance, only for an instant but nonetheless definite. Susan tried it with the other wrist; it was the same. So Nancy Greenly was not totally flaccid. Susan felt a certain sense of academic pleasure; the irrational joy of the positive finding.

Susan found a percussion hammer for tendon reflexes. It was made of hard red rubber with a stainless steel handle. She had had one used on herself and had tried one on fellow students in physical diagnosis classes, but never used one on a patient. Clumsily Susan tried to elicit a reflex by tapping Nancy Greenly’s right wrist. Nothing. But Susan was not exactly sure where to tap. Instead she pulled up the sheet on the right side and tapped under the knee. Nothing. She flexed the knee with her left hand and tapped again. Still nothing. From neuroanatomy class Susan remembered that the reflex she was searching for came from a sudden stretch of the tendon. So she stretched Nancy Greenly’s knee more, then tapped. The thigh muscle contracted almost imperceptibly. Susan tried it again, eliciting a reflex that was no more than a slight tightening of the flaccid muscle. Susan tried it on the left leg, with the same result. Nancy Greenly had weak but definite reflexes, and they were symmetrical.

Susan tried to think of other parts of the neurological examination. She remembered level-of-consciousness testing. In Nancy Greenly’s case the only test would be reaction to pain stimulus. Yet when she pinched Nancy Greenly’s Achilles tendon, there was no response no matter how hard she squeezed. Without any specific reason other than wondering if the pain sensation would be more potent the closer to the brain, Susan pinched Nancy Greenly’s thigh and then recoiled in horror. Susan thought that Nancy Greenly was getting up because her body stiffened, arms straightening from her sides and rotating inward in a painful contraction. There was a side-to-side chewing motion with her jaw almost as if she were awakening. But it passed and Nancy Greenly reverted to her limpness equally suddenly. Eyes widening, Susan had moved back, pressing herself against the wall. She had no idea what she had done or how she had managed to do it. But she knew she was toying in the area well beyond her present abilities and knowledge. Nancy Greenly had had a seizure of some kind, and Susan was immensely thankful that it had passed so quickly.

Guiltily, Susan glanced around the room to see if anyone was watching. She was relieved to note that no one was. She was also relieved that the cardiac monitor above Nancy Greenly continued its steady and normal pace. There were no premature contractions.

Susan had the uncomfortable feeling that she was doing something wrong, that she was trespassing, and that any moment she would be deservedly reprimanded, perhaps by Nancy Greenly’s arresting once again. Susan quickly decided that she would withhold further patient examination until after some serious reading.

With great effort at appearing nonchalant, Susan made her way over to the central desk. The charts were kept in a circular stainless steel file built into the counter top. With her left hand she began to turn the chart rack slowly. It squeaked painfully. Susan turned it more slowly. The squeak persisted.

“Can I help you?” asked June Shergood from behind Susan, causing her to start and to withdraw her hand as if she were a child caught at the cookie jar.

“I’d just like the chart,” said Susan, expecting some sour words from the nurse.

“What chart?” Shergood’s voice was pleasant.

“Nancy Greenly’s. I’m going to try to get an idea about her case so that I can participate in her care.”

June Shergood rummaged among the charts, coming up with Nancy Greenly’s. “You might find it easier to concentrate in there,” said Shergood with a smile, pointing toward a door.

Susan thanked her, welcoming the opportunity to withdraw. The door that Shergood had indicated opened into a tiny room ringed about with glass-faced, locked medicine cabinets. A counter top ran around three sides of the room, providing desk space. On the right was a sink, and in the left corner was the omnipresent coffeepot.

Susan sat down with the chart. Although Nancy Greenly had not been in the hospital for even two weeks, her chart was voluminous. That was usual for a case placed in the ICU. The elaborate, constant care generated reams of paper.

Susan took out the remains of her tuna sandwich and milk and poured herself a cup of coffee. Then she took out her notebook and removed a number of blank pages. She started to work. Unaccustomed to using a patient chart, she spent a few minutes figuring out its organization. The order sheets were first, followed by the graphs of the patient’s vital signs. Next was the history and physical examination dictated on the day of admission. The rest of the chart included the progress notes, the operative and anesthesia notes, the nurses’ notes, and the innumerable laboratory values, X-ray reports, and records of sundry tests and procedures.