Coma (12 page)

“How right you are,” said Dr. Goodman cheerfully. He let I.V. fluid run through the tube onto the floor to remove the bubbles. “This should be a rapid case. Dr. Spallek is one of the fastest surgeons I know and the patient is a healthy young man. I bet we’re out of here by one.”

Dr. Norman Goodman had been on the staff at the Memorial for eight years and held a joint appointment at the medical school. He had a lab on the fourth floor of the Hilman Building with a large population of monkeys. His interests involved developing newer concepts of anesthesia by selectively controlling various brain areas. He felt that eventually drugs were going to be specific enough so that just the reticular formation itself would be altered, thereby reducing the amount of drugs necessary to control anesthesia. In fact, only a few weeks earlier he and his laboratory assistant, Dr. Clark Nelson, had stumbled onto a butyrophenone derivative which had slowed the electrical activity only in the reticular formation of a monkey. With great discipline he had kept himself from becoming overly encouraged at such an early time, especially when the results had been from a single animal. But then the results had become reproducible. So far he had tested eight monkeys and all had responded the same.

Dr. Norman Goodman would have preferred to give up all activities and devote twenty-four hours a day to his new discovery. He was eager to advance to more sophisticated experiments with his drug, especially a trial on a human. Dr. Nelson, if anything, was even more eager and optimistic. It had been with difficulty that Dr. Goodman had talked Dr. Nelson out of trying a small subpharmacological dose on himself.

But Dr. Goodman knew that true science rested on a foundation of painstaking methodology. One had to proceed slowly, objectively. Premature trials, claims, or disclosure could be disastrous for all concerned. Accordingly Dr. Goodman had to rein in his excitement and maintain his normal schedule and commitments unless he was willing to divulge his discovery; and that he was unwilling to do as yet. So on Monday morning he had to “pass gas,” as they called it in the vernacular . . . devote time to clinical anesthesia.

“Damn,” said Dr. Goodman straightening up. “Mary, I forgot to bring down an endotracheal tube. Would you run back to the anesthesia room and bring me a number eight.”

“Coming up,” said Mary Abruzzi, disappearing through the OR door. Dr. Goodman sorted out the gas
line connectors and plugged into the nitrous oxide and oxygen sources on the wall.

Sean Berman was Dr. Goodman’s fourth and final case for February 23, 1976. Already that day he had smoothly anesthetized three patients. A two-hundred-and-sixty-seven-pound flatulent female with gallstones had been the only potential problem. Dr. Goodman had feared that the enormous bulk of fatty tissue would have absorbed such large quantities of the anesthetic agent that termination of the anesthesia would have been very difficult. But that had not proved to be the case. Despite the fact that the case had been prolonged the patient had awakened very quickly and extubation had been carried out almost immediately after the final skin suture had been tied.

The other two cases that morning had been very routine: a vein stripping and a hemorrhoid. The final case for Dr. Goodman, Berman, was to be a meniscectomy of the right knee and Dr. Goodman expected to be in his lab by 1:15 at the latest. Every Monday morning Dr. Goodman thanked his lucky stars that he had had enough foresight to have continued his research proclivities. He found clinical anesthesia a bore; it was too easy, too routine, and frightfully dull.

The only way he kept his sanity those Monday mornings, he’d tell his neighbor, was to vary his technique to provide food for his brain, to force him to think rather than just sit there and daydream. If there were no contraindications, he liked balanced anesthesia the best, meaning he did not have to give the patient some gargantuan dose of any one agent, but rather he balanced the needs by a number of different agents. Neurolept anesthesia was his favorite because in certain respects it was a crude precursor to the types of anesthetic agents he was looking for.

Mary Abruzzi returned with the endotracheal tube.

“Mary, you’re a doll,” said Dr. Goodman, checking off his preparations. “I think we’re ready. How about bringing the patient down?”

“My pleasure. I’m not going to get lunch until we finish this case.” Mary Abruzzi left for the second time.

Since Berman did not offer any contraindications, Goodman decided to use neurolept anesthesia. He knew Spallek didn’t care. Most orthopedic surgeons didn’t care. “Just get them down enough so I can put on
the Goddamn tourniquet, that’s all I care about” was the usual orthopedic response to the query about which anesthetic agent they might prefer.

Neurolept anesthesia was a balanced technique. The patient was given a potent neurolept, or tranquilizing agent, and a potent analgesic, or painkiller. Both agents provided easily arousable sleep as a side effect. Dr. Goodman liked droperidol and fentanyl best of the agents cleared for use. After they were given, the patient was put to sleep with Pentothal and maintained asleep on nitrous oxide. Curare was used to paralyze the skeletal muscles for entubation and surgical relaxation. During the case aliquots of the neurolept and analgesic agents were used as needed to maintain the proper depth of anesthesia. The patient had to be watched very closely through all this, and Dr. Goodman liked that. For him the time passed more quickly when he was busy.

The OR door was opened by one of the orderlies helping to guide Berman’s gurney into room No. 8. Mary Abruzzi was pushing.

“Here’s your baby, Dr. Goodman. He’s sound asleep,” said Mary Abruzzi.

They put down the arm rails.

“OK, Mr. Berman. Time to move over onto the table.” Mary Abruzzi gently shook Berman’s shoulder. He opened his eyelids about halfway. “You have to help us, Mr. Berman.”

With some difficulty they got Berman over onto the table. Smacking his lips, turning on his side, and drawing up the sheet around his neck, Berman gave the impression that he thought he was home in his own bed.

“OK, Rip Van Winkle, on your back.” Mary Abruzzi coaxed Berman onto his back and secured his right arm to his side. Berman slept, apparently unaware of the activity about him. The cuff of the pneumatic tourniquet was placed about his right thigh and tested. The heel of his right foot was placed in a sling and hung from a stainless steel rod at the foot of the operating table, lifting the entire right leg. Ted Colbert, the assisting resident, began the prep by scrubbing the right knee with pHisoHex.

Dr. Goodman went right to work. The time was 12:20. Blood pressure was 110/75; pulse was seventy-two and regular. He started an I.V. with deftness which belied the difficulties of handling a large-bore
intravenous catheter. The whole process from skin puncture to tape took less than sixty seconds.

Mary Abruzzi attached the cardiac monitor leads, and the room echoed with the high-pitched but low-amplitude beeps.

With the anesthesia machine rigged and ready, Dr. Goodman attached a syringe to the I.V. line.

“OK, Mr. Berman, I want you to relax now,” kidded Dr. Goodman, smiling at Mary Abruzzi.

“If he relaxes any more, he’s going to pour off the table,” laughed Mary.

Dr. Goodman injected intravenously a 6 cc bolus of Innovar, the same droperidol and fentanyl combination that had been used as the pre-op medication. Then he tested the lid reflex and noted that Berman had already achieved a deep level of sleep. Consequently Dr. Goodman decided that the Pentothal was not needed. Instead he began the nitrous oxide/oxygen mixture by holding the black rubber mask over Berman’s face. Blood pressure was 105/75; pulse was sixty-two and regular. Dr. Goodman injected 0.4 mg of d-tubocurarine, the drug which represents a debt modern society owes to the Amazon peoples. There were a few muscle twitches in Berman’s body, then relaxation followed; breathing stopped. The entubation was rapid and Dr. Goodman inflated Berman’s lungs with the ventilating bag while he listened to each side of the chest with his stethoscope. Both sides aerated evenly and fully.

Once the pneumatic tourniquet was cajoled into functioning, Dr. Spallek breezed into the room, and the case went rapidly. Dr. Spallek was into the joint in one dramatic slice.

“Voilá,”
he said, holding the scalpel in the air and tilting his head to admire his handiwork. “And now for the Michelangelo touch.”

Penny O’Rilley’s eyes rolled up inside of her head in response to Dr. Spallek’s theatrics. She handed him the meniscus knife with a trace of a smile on her lips.

“Anoint my blade,” said Dr. Spallek holding the knife out for the resident to squirt irrigation fluid over its tip.

The knife was then inserted into the joint and for a few moments Dr. Spallek rooted around blindly, his face upturned toward the ceiling. He was cutting by feel alone. There was a faint grinding sound, then a snap.

“OK,” said Dr. Spallek tightening his teeth, “here comes the culprit.”

Out came the damaged cartilage. “Now I want everyone to see this. See this little tear on the inside edge. That’s what’s been causing this chap’s problems.”

Dr. Colbert looked from the specimen to Penny O’Rilley. They both nodded approval while both secretly wondered if the little tear hadn’t been caused by the blind cutting with the meniscus knife.

Dr. Spallek stepped back from the table, pleased with himself. He snapped off his gloves. “Dr. Colbert, why don’t you close up. 4-0 chromic, 5-0 plain, then 6-0 silk for the skin. I’ll be in the lounge.” Then he was gone.

Dr. Colbert dabbed ineffectually at the wound for a few moments.

“How much longer do you estimate?” questioned Dr. Goodman over the ether screen.

Dr. Colbert looked up. “Fifteen or twenty minutes, I guess.” He palmed a pair of toothed forceps and took the first suture from Penny O’Rilley. He took a bite with the suture and Berman moved. At the same time Dr. Goodman felt a tenseness in the ventilating bag when he tried to breathe Berman. He sensed that Berman was trying to breathe on his own. Concurrently the blood pressure rose to 110/80.

“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 well. 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-tooth forceps were in his left hand.