Coma (16 page)

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 looseleaf 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 countertop. 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 countertop 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.

Since she did not know what she was looking for, Susan decided to make copious notes. At this early stage there was no way of determining what was going to be the important information. She started with Nancy Greenly’s name, age, sex, and race. Next she included the meager medical history attesting to the fact that Nancy Greenly had been a healthy individual. There were bits and pieces of family history, including reference to a grandmother who had had a stroke. The only illness of note in Nancy’s past was a case of mononucleosis at age 18, with an apparently uneventful recovery. The reviews of Nancy’s systems, including her cardiovascular and respiratory systems, were normal. Susan wrote down the laboratory values from her routine pre-op screen: the blood and urine were both normal. She also wrote down the results of the pregnancy test, negative; various blood clotting studies, blood type, tissue type, chest X-ray, and EKG. There was also the chemistry profile, which included a wide battery of tests. Nancy Greenly’s reports were well within normal limits.

Susan ate the last of the tuna sandwich and washed it down with a slug of milk. Turning the pages of the operative section and locating the anesthesia record, she noted the pre-op medication: Demerol and
Phenergan given at 6:45
A.M.
by one of the nurses on Beard 5. The endotracheal tube was a number 8. Pentothal 2 grams given I.V. at 7:24
A.M.
Halothane, nitrous oxide, and oxygen started at 7:25. The halothane concentration was initially 2 percent through the Fluotec Temperature Compensated Vaporizer. Within several minutes it was reduced to 1 percent. The nitrous oxide and oxygen flow rates were 3 liters and 2 liters per minute respectively. For muscle relaxation a 2 cc dose of 0.2 percent succinylcholine was given at 7:26 and a second dose at 7:40.

Susan noted that the blood pressure fell at 7:48 after maintaining a plateau of 105/75. The halothane percentage was reduced to 1/2 percent at that point, while the nitrous oxide and oxygen flow was changed to 2 and 3 liters. The blood pressure drifted back up to 100/60. Susan made a rough copy of the information which was graphed in the anesthesia record.

But from that point on the anesthesia record became hard to decipher. As far as Susan could tell, the blood pressure and the pulse stayed about 100/60 and seventy per minute respectively. Although the heart rate stayed stable, there was some sort of variation in the rhythm, but Dr. Billing had not described it.

From the record Susan could see that Nancy Greenly had been moved from the OR into the recovery room at 8:51. A Block Ade square-wave nerve stimulator had been used to test the function of Nancy’s peripheral nerves. It had been originally suspected that she had been unable to metabolize the additional dose of succinylcholine. But the nerve function had been detected in both ulnar nerves, meaning that the problem was most likely central, in the brain.

Over the following hour Nancy Greenly had been given Narcan 4 mg to rule out an idiosyncratic hypersusceptibility to her pre-op narcotic. There had been no response. At 9:15 she had been given neostigmine 2.5 mg to see if the block on her nerves and hence her paralysis was due to a curarelike competitive block despite the result of the nerve stimulator test. Nancy Greenly had also been given two units of fresh frozen plasma with documented cholinesterase activity to try to eliminate any succinylcholine that might have still remained. Both these measures resulted in some mild twitching of a few muscles but no real response.

The anesthesia record ended with the terse statement in Dr. Billing’s handwriting: “Delayed return of consciousness post anesthesia; cause unknown.”

Susan next turned to the operative report dictated by Dr. Major.

DATE
: February 14, 1976

PRE OP DIAGNOSIS
: Dysfunctional uterine bleeding

POST OP DIAGNOSIS
: Same

SURGEON
: Dr. Major

ANESTHESIA
: General endotracheal using halothane

ESTIMATED BLOOD LOSS
: 500 cc

COMPLICATIONS: Prolonged return to consciousness after the termination of anesthesia

PROCEDURE: After appropriate pre-op medication (Demerol and Phenergan) the patient was brought to the operating room and attached to the cardiac monitor. She was smoothly inducted under general anesthesia utilizing an endotracheal tube. The perineum was prepped and draped in the usual fashion. A bimanual examination was carried out revealing normal ovaries, adnexa and an antero-flexed uterus. A #4 Pederson speculum was inserted into the vagina and secured. Blood clots were sucked from the vaginal vault. The cervix was inspected and appeared normal. The uterus was sounded to 5 cm with a Simpson sound. Cervical dilation was carried out with ease and minimal trauma. Cervical dilators #1 through #4 were passed with ease. A #3 Sime curette was passed and the endometrium was curetted. A specimen was sent to the laboratory. Bleeding was minimal at the termination of the procedure. The speculum was removed. At that point it became apparent that the patient was making a slow recovery from anesthesia.

Susan rested her weary right hand by letting it dangle by her side. She had a habit of writing by holding a pencil or pen so tightly that blood flow was restricted. The blood tingled as it returned to her fingertips. Before going back to work, she took several sips of her coffee.

The pathology report described the endometrial scrapings as proliferative in character. The diagnosis was then listed as anovulatory uterine bleeding with a proliferative endometrium. No clue there.

Next Susan turned to the most interesting page: the initial neurology consult, signed by a Dr. Carol Harvey. Without knowing the meaning of most of what she wrote, Susan copied the consult note as well as she could. The handwriting was atrocious.

HISTORY
: The patient is a twenty-three-year-old, white female admitted to the hospital with a problem of (illegible phrase). Past medical history of self and family negative for significant neurological disorders. Patient’s pre-op workup (illegible phrase). Surgery itself uneventful and immediate result diagnostic and most likely curative of the presenting complaint. However, during surgery some minor problems with the blood pressure were noted, and after surgery there was noted a prolonged unconsciousness and apparent paralysis. Overdose of succinylcholine and/or halothane ruled out. (Entire sentence totally illegible.)