Coma (3 page)

Nancy’s tongue was paralyzed and it fell back, blocking her airway. But that didn’t matter. The muscles of the thorax and abdomen were paralyzed as well, and any attempt at breathing ceased. Although chemically different from the curare of the Amazon savages, the drug had the same effect, and Nancy would have died in five minutes. But at this point nothing was wrong. Dr. Billing was in total control. The effect was expected and desirable. Outwardly calm, inwardly very tense, Dr. Billing put down the breathing mask and reached for the laryngoscope, step number 22 on his list. With the tip of the blade, he pulled the tongue forward and maneuvered past the white epiglottis, while he visualized the entrance to the trachea. The vocal cords were ajar, paralyzed with the rest of the skeletal muscles.

Swiftly Dr. Billing squirted some topical anesthetic into the trachea, followed by the endotracheal tube. The laryngoscope made a characteristic metallic snap as Dr. Billing folded the blade onto the handle. With the help of a small syringe, he inflated the cuff on the endotracheal tube, providing a seal. Quickly he attached the tip of the rubber hose, without the face mask, to the open end of the endotracheal tube. As he compressed the ventilating bag, Nancy’s chest rose in a symmetrical fashion. Dr. Billing listened to Nancy’s chest with his stethoscope and was pleased. The entubation had been as characteristically smooth as expected. He was in total control of the patient’s respiratory state. He adjusted his flow meters and set the combination of halothane, nitrous oxide, and oxygen he wanted. A few pieces of tape secured the endotracheal tube. A twist of the finger adjusted the I.V. rate. Dr. Billing’s own heart began to slow down. He never showed it, but he always got very tense during the entubation procedure. With the patient paralyzed one has to work fast, and do it right.

With a nod, Dr. Billing indicated that Gloria D’Mateo could begin the prep of Nancy’s shaved perineum. Meanwhile Dr. Billing began to make himself comfortable for the case. His job was now reduced to close observation of the patient’s vital signs: heart rate and rhythm, blood pressure, and temperature. As long as the patient was paralyzed, he had to compress the ventilating bag, to breathe the patient. The succinylcholine would wear off in eight to ten minutes; then the patient could breathe herself, and the
anesthesiologist could relax. Nancy’s blood pressure stayed at 105/70. The pulse had steadily fallen from the anxiety state prior to anesthesia to a comfortable seventy-two beats per minute. Dr. Billing was happy, and he looked forward to a coffee break in about forty minutes.

The case went smoothly. Dr. Major did his bimanual examination and asked for some more relaxation. This meant that Nancy’s blood had detoxified the succinylcholine given during the entubation. Dr. Billing was happy to give another 2 cc. He dutifully recorded this in his anesthesia record. The result was immediate, and Dr. Major thanked Dr. Billing and informed the crew that the ovaries felt like little smooth, normal plums. He always said that when he felt normal ovaries. The dilation of the cervix went without a hitch. Nancy had a normally antero-flexed uterus, and the curve on the dilators was a perfect match. A few blood clots were sucked out from the vaginal vault with the suction machine. Dr. Major carefully curetted the inside of the uterus, noting the consistency of the endometrial tissue. As Dr. Major passed the second curette, Dr. Billing noted a slight change in the rhythm of the cardiac monitor. He watched the electronic blip trace across the oscilloscope screen. The pulse fell to about sixty. Instinctively he inflated the blood pressure cuff and listened intently for the familiar faraway deep sound of the blood surging through the collapsed artery. As the air pressure drained off more, he heard the rebound sound indicating the diastolic pressure. The blood pressure was 90/60. This was not terribly low, but it puzzled his analytical brain. Could Nancy be getting some vagal feedback from her uterus, he wondered. He doubted it, but just the same he took the stethoscope from his ears.

“Dr. Major, could you hold on for just a minute? The blood pressure has sagged a little. How much blood loss do you estimate?”

“Couldn’t be more than 500 cc,” said Dr. Major, looking up from between Nancy’s legs.

“That’s funny,” said Dr. Billing, replacing the stethoscope in his ears. He inflated the cuff again. Blood pressure was 90/60. He looked at the monitor: pulse sixty.

“What’s the pressure?” asked Dr. Major.

“Ninety over sixty, with a pulse of sixty,” said Dr. Billing, taking the stethoscope from his ears and rechecking the flow valves on the anesthesia machine.

“What the hell’s wrong with that, for Christ’s sake?” snapped Dr. Major, showing some early surgical irritation.

“Nothing,” agreed Dr. Billing, “but it’s a change. She had been so steady.”

“Well, her color is fantastic. Down here, she’s as red as a cherry,” said Dr. Major, laughing at his own joke. No one else laughed.

Dr. Billing looked at the clock. It was 7:48. “OK, go ahead. I’ll tell you if she changes any more,” said Dr. Billing, while giving the breathing bag a healthy squeeze to inflate Nancy’s lungs maximally. Something was bothering Dr. Billing; something was keying-off his sixth sense, activating his adrenals and pushing up his own heart rate. He watched the breathing bag sag and remain still. He compressed it again, mentally recording the degree of resistance afforded by Nancy’s bronchial tubes and lungs. She was very easy to breathe. He watched the bag again. No motion, no respiratory effect on Nancy’s part, despite the fact that the second dose of the succinylcholine should have been metabolized by then.

The blood pressure came up slightly, then went down again: 80/58. The monotonous beep of the monitor skipped once. Dr. Billing’s eyes shot to the oscilloscope screen. The rhythm picked up again.

“I’ll be finished here in five minutes,” said Dr. Major for Dr. Billing’s benefit. With a sense of relief, Dr. Billing reached over and turned down both the nitrous oxide and the halothane flow, while turning up the oxygen. He wanted to lighten Nancy’s level of anesthesia. The blood pressure came up to 90/60, and Dr. Billing felt a little better. He even allowed himself the luxury of running the back of his hand across his forehead to scatter the beads of perspiration that had appeared as evidence of his increasing anxiety. He glanced at the soda-lime CO
₂
absorber. It appeared normal. Time was 7:56. With his right hand he reached up and lifted Nancy’s eyelids. They moved with no resistance and the pupils were maximally dilated. The fear returned to Dr. Billing in a rush. Something was wrong . . . something was very wrong.

February 23

7:15 A.M.

Several small flakes of snow danced down Longwood Avenue in the half-light of February 23, 1976. The temperature was a crisp twenty degrees and the delicate crystalline structures fluttering earthward were intact even after striking the pavement. The sun was obscured by a low cover of thick gray clouds which shrouded the waking city. More and more clouds were swept in by the sea breeze, enveloping the tops of the taller buildings in a mist, making it become paradoxically darker as dawn spread its frail fingers over Boston. It was not supposed to snow, yet a few flakes had crystallized over Cohasset and had blown all the way into the city. The few that reached Longwood Avenue and were blown right on Avenue Louis Pasteur were the survivors until a sudden downdraft slammed them against a third-story window of the medical school dorm. They would have slid off had it not been for the layer of greasy Boston grime on the pane. Instead they stuck there while the glass slowly transmitted the heat from within, and their delicate bodies dissolved and mingled with the dirt.

Within her room Susan Wheeler was totally unaware of the drama on the windowpane. Her mind was preoccupied with extracting itself from the clutches of a meaningless, disturbing dream after a restless, near-sleepless night. February 23 was going to be a difficult day at best and possibly a disaster. Medical school is
made up of a thousand minor crises occasionally interrupted by truly epochal upheavals. February 23 was in the latter category for Susan Wheeler. Five days earlier she had completed the first two years of medical school, the basic science part taught in the lecture halls and science labs with books and other inanimate objects. Susan Wheeler had done very well because she could handle the classroom, the lab, and the papers. Her class notes were renowned and people always wanted to borrow them. At first she lent them indiscriminately. Later, as she began to perceive the realities of the competitive system which she thought she had left behind in Radcliffe, she changed her tactics. She lent her notes only to a small group of people who were her friends, or at least were people from whom she could borrow notes if she had had to miss a class. But she rarely missed a class.

A number of people chided Susan playfully about her marvelous attendance record. She always responded by saying she needed all the help she could get. Of course that was not the reason. Having entered a profession dominated by males, in which essentially all the professors and instructors were males, Susan Wheeler could not skip a class without being missed. Despite the fact that Susan looked on her mentors in a neutral sexless way as her professional superiors, they did not return the view in kind. The fact of the matter was that Susan Wheeler was a very attractive twenty-three-year-old female.

Her hair was the color of winter wheat and very wispy. Since it was long and fine it drove her batty in the wind unless she had it pulled back and clasped with a barrette at the back of her head. From there it fell in a sheen to the lower edges of her shoulder blades. Her face was broad with high cheekbones, and her eyes, set well back in their sockets, were a mixture of blue and green with flecks of brown so that the chromatic effect changed with different light sources. Her teeth were ultra white and perfectly straight, the result of fifty percent nature and fifty percent suburbanite orthodontist.

All in all Susan Wheeler appeared like the girl of the Pepsi-Cola people’s dreams. At twenty-three years old she was young, healthy, and sexy with that American, Californian style that made eyes turn and hypothalamuses awaken. And on top of it all, perhaps in spite of it all, Susan Wheeler was very sharp. Her grammar school IQ ratings had hovered around the 140 range and were a source of infinite delight to her socially committed parents. Her school record was a monotonous series of A’s with numerous other
evidences of achievement. Susan liked school and learning and reveled in using her brain. She read voraciously. Radcliffe had been perfect for her. She did well but she earned her grades. She had majored in chemistry but had taken as much literature as possible. She had no trouble getting into medical school.

But being attractive as Susan was had certain definite drawbacks. One was the difficulty of missing class without being noticed. Whenever questions were asked, she was among those unfortunate few who served to demonstrate the stupidity of the students or the brilliance of the professors. Another drawback was that people formed opinions about Susan, with very little information. She so resembled models glaring out from advertisements that people continuously confused her with those frequently mindless girls.

There were advantages, though, to being bright and beautiful, and Susan was slowly beginning to realize that it was reasonable to exploit them to a degree. If she needed a further explanation regarding some complicated topic, she only had to ask once. Instructors and professors alike would hasten to help Susan understand a fine point of endocrinology or a subtle point of anatomy.

Socially, Susan did not date as much as people imagined she would. The explanation for this paradox was severalfold. First, Susan preferred reading in her room to a boring date, and with her intelligence, Susan found quite a few men boring. Second, few men actually asked Susan out, just because Susan’s combination of beauty and brains was a bit intimidating. Susan spent many Saturday nights engrossed in novels, some literary, some otherwise.

Starting February 23, Susan feared her comfortable world was going to be blown up. The familiar lecture routine was over. Susan Wheeler and one hundred and twenty-two of her classmates were being rudely weaned from the security of the inanimate and tossed into the arena of the clinical years. All the confidence in one’s abilities formed during the basic science years were hardly proof against the uncertainties of actual patient care.

Susan Wheeler had no illusions concerning the fact that she knew nothing about actually being a doctor, about taking care of real live patients. Inwardly she doubted that she ever would. It wasn’t something she could read about and assimilate intellectually. The idea of trial by fire was diametrically opposed to her basic methodology. Yet on February 23 she was going to have to deal with patients some way, somehow. It was
this crisis of confidence that made sleep difficult for her and filled the night with bizarre, disturbing dreams in which she found herself wandering through foreign mazes searching for horrible goals. Susan had no idea how closely her dreams would approximate her experience during the next few days.

At 7:15 the mechanical click of the clock radio broke her dream’s feedback circuit and Susan’s brain awakened to full consciousness. She turned off the radio before the transistors had a chance to fill the room with raucous folk music. Normally she relied on the music to wake her. But on this particular morning she needed little assistance. She was too keyed up.

Susan put her feet onto the floor and sat on the edge of the bed. The floor was cold and uninviting. Her hair descended from her head, haphazardly, leaving only a two-to-three-inch gap through which to regard her room. It wasn’t much of a room, about twelve by fourteen feet, with two multipaned windows at the end. The windows gave out onto another brick building and a parking lot so that Susan rarely looked out. The paint was reasonably fresh because she had painted the room herself about two years previously. The color was a pleasing pastel yellow which accented perfectly the Marimekko Printex fabric she had used to make the curtains. Their colors were several shades of electric green, separated by dark blue. On the walls hung a variety of colorful posters, framed with stainless steel, advertising past cultural events.