Coma (35 page)

“You’re getting more and more clever, Mark.”

“You do realize that you’re now breaking the law.”

Susan nodded in agreement, looking down at the pile of paper filled with her tiny writing.

Bellows’s eyes followed hers.

“Well, have they shed any light on this . . . this crusade of yours?”

“Not much, I’m afraid. At least not yet, or at least I’ve not been clever enough to spot it. I wish I had all the charts. So far the ages have all been relatively young, twenty-five to forty-two. Otherwise they seem to be of random sex, racial background, social background. I can’t find any relationship in their previous medical histories. Their vital signs and progress up until the onset of coma were uncomplicated in all cases. Their personal physicians were all different. Of the surgical cases, only two had the same anesthesiologist. The anesthetic agents were varied, as expected. There were some overlaps in the preoperative medications. A number of the cases had Demerol and Phenergan, but others had totally different agents. Innovar was used
on two cases. But all that’s not surprising.

“It does seem, as far as I can tell without going up in the OR, that most if not all the surgical cases occurred in room eight. That does seem a little strange, but then again that’s the room used most often for the shorter operations. And this problem is most often associated with the shorter operations. So that’s probably to be expected as well. Laboratory values are all generally normal. Oh, by the way, all cases seemed to have been blood-typed and tissue-typed. Is that normal procedure?”

“They blood-type most surgical patients, especially if they anticipate much blood loss during the operation. Tissue-typing is not usual, although the lab may be doing it as part of a check on new equipment or new tissue-typing sera. See if there is an accounting number on one of the lab reports on the typing.”

Susan flipped back through the pages of the chart in front of her until she located the tissue-type report.

“No, there’s no accounting number.”

“Well, that explains that, then. The lab is doing it at their expense. That’s not abnormal.”

“The medical patients were all on I.V.s for one reason or another.”

“So are ninety percent of the people in the hospital.”

“I know.”

“Sounds like you got a lot of nothing.”

“I’d have to agree at this point.” Susan paused, sucking on her lower lip. “Mark, before the endotracheal tube is placed in a patient during anesthesia, the anesthesiologist paralyzes the patient with succinylcholine. Isn’t that right?”

“Succinylcholine or curare, but usually succinyl.”

“And when a patient is given a pharmacological dose of succinylcholine, he can’t breathe.”

“That’s true.”

“Couldn’t an overdose of succinylcholine be the way these patients are rendered hypoxic? If they can’t breathe, then oxygen doesn’t get to the brain.”

“Susan, the anesthesiologist gives succinylcholine and then monitors the patient like a hawk; he even breathes for the patient. If there is too much succinylcholine, it just means the anesthesiologist has to breathe
the patient for a longer time until the patient metabolizes the drug. The paralyzing effect is completely reversible. Besides, if something like that were being done maliciously, all the anethesiologists in the hospital would have to be involved, and that’s hardly likely. And maybe even more important is the fact that under the combined eye of the anesthesiologist and the surgeon, who can actually see how red the blood is and how well it is oxygenated, it would be absolutely impossible to alter the patient’s physiologic state without one or both knowing it. When blood is oxygenated, it is bright red. When oxygen gets low, the blood becomes dark brownish-bluish-maroon. The anesthesiologist meanwhile is breathing the patient, constantly checking the pulse and blood pressure, and watching the cardiac monitor. Susan, you are hypothesizing some sort of foul play, and you don’t have a why or a who or a how. You’re not even sure you have a victim.”

“I’m sure I have a victim, Mark. It might not be a new disease but it’s something. One more question. Where do the anesthetic gases come from that the anesthesiologists use?”

“It varies. Halothane comes in cans like ether. It’s a liquid and it’s vaporized as needed in the OR. Nitrous, oxygen, and air come from central sources and are piped into the ORs. There are standby cylinders of oxygen and nitrous oxide in the OR for emergency use. . . . Look, Susan, I’ve got a little more work to do, then I’m free. How about coming over to the apartment for a drink?”

“Not tonight, Mark. I want to get a good night’s sleep and I’ve got a few more things to do. But thanks. Also, I’ve got to get these charts back to their hiding place. After that I intend to look around in OR room number eight.”

“Susan, I personally think you should get your ass out of this hospital before you really get yourself in hot water.”

“You’re entitled to your opinion, Doctor. It’s just that this patient doesn’t feel like following orders.”

“I think you’re carrying all of this too far.”

“You do, do you? Well, I might not have a who, but I’ve got a number of suspects. . . .”

“Sure you do. . . .” Bellows fidgeted. “Are you going to make me guess or are you going to tell me?”

“Harris, Nelson, McLeary, and Oren.”

“You’re out of your squash!”

“They all act as guilty as hell and want me out of here.”

“Don’t confuse defensive behavior with guilt, Susan. After all, complications are hard to live with in medicine, no matter from what cause.”

February 25

11:25 P.M.

Susan felt a definite sense of relief when she had returned the charts to their hiding place in McLeary’s closet. At the same time, she was very disappointed. Having finally inspected them was an anticlimax of sorts. She had placed a great deal of emphasis on the importance of the charts, but after she had finished studying them, she felt no further in her mission. She had a lot more data but no correlates, no intercepts. The cases still seemed to be random and unassociated.

The elevator slowed and stopped, the door quivered, then opened. Susan stepped out into the OR area. There was still a case going on in room No. 20, a ruptured abdominal aneurysm that had been admitted through the emergency room. The operation had been in progress for over eight hours; that didn’t look so good. Otherwise the OR area was in its nightly repose. There were a few people busy cleaning the floor and restocking the supply room with freshly laundered linen. A girl in a scrub dress was behind the main desk, trying to fit the last few cases into the following day’s master schedule.

The nurse’s uniform ruse was still working well for Susan and the few people in the hall did not seem to notice her passing. She went directly to the nurses’ locker rooms and changed into a scrub dress, hanging the nurse’s uniform in an open locker.

Reentering the main hall, Susan eyed the swinging doors into the area of the operating rooms. A large sign on the right door said: “Operating Room Area: Unauthorized Entry Forbidden.” The main desk was just to the side of these doors. The nurse sitting behind the desk was still hard at work. Susan had no idea if she would be challenged if she tried to enter.

In order to survey the scene in its totality, Susan walked the length of the hall several times, half-hoping the girl at the main desk would take a break and leave. But she didn’t budge, nor even look up. Susan tried to think of some appropriate explanation in case the girl questioned her. But she couldn’t think of any. It was almost midnight and she knew she’d have to have some reasonably convincing story to explain her presence.

Finally, with no cover story in mind except for some weak comment about wanting to check on progress in room No. 20, or being sent up from the lab to do random cultures for contamination, Susan made her move. Pretending not to notice the girl at the desk, she headed for the doors. As she passed, the girl did not look up. A few more steps. When Susan reached the doors, she straight-armed the one on the right. It opened and Susan was about to enter.

“Hey, just a minute.”

Susan froze, waiting for the inevitable. She turned to face the girl.

“You forgot your conductive boots.”

Susan looked down at her shoes. As it dawned on her what the nurse was concerned about, Susan felt relieved.

“Damn, you’d think this was my second time in the OR.”

The nurse’s attention went back to the master schedule. “I forget the bastards now and then myself.”

Susan walked over to a stainless steel cabinet against the wall. The conductive booties—designed to prevent static electricity, so hazardous where inflammable gas was flowing—were kept in a large cardbox box on the lower shelf. Susan put them on the way Carpin had shown her on the first visit to the OR two days before, tucking the black tapes inside her shoes. When she opened the swinging door the second time, the nurse at the desk didn’t even look up. The Memorial was large enough so that new faces were to be expected.

The operating rooms at the Memorial were grouped in a large U-shape with supply, holding area, and anesthesia offices in the center. The entrance to the OR area was at the bottom of the U and the recovery room was on the left arm of the U, closest to the elevators. Susan found that room No. 8 was on the right arm of the U, on the outside.

No. 20, where the operation continued, was in the opposite direction, and Susan found herself quite alone approaching room No. 8. Pausing at the door, she looked through the glass. It looked exactly like room No. 18, where Niles had passed out. The walls were tile, the floor a speckled vinyl. Although the lights were out, Susan could see the large kettledrum operating lights above, and the operating table immediately below. She opened the door and turned on the lights.

Without any specific objective in mind, Susan roamed around the room, noticing the larger objects. Then in a more systematic fashion she began to examine details. She found the gas line terminals, noticing that oxygen had a green male connector. The nitrous connector was blue and structurally different so that no mistake could be made. A third male connector was not labeled or colored. Susan assumed it was the compressed air line. A larger female connector was labeled “suction”; above it was a gauge with a large adjusting dial.

In the back of the room were a number of stainless steel cabinets filled with various supplies. There was a desk of sorts for the circulating nurse. The right wall had an X-ray screen. The rear wall, next to the door, had a large institutional clock. The large red second hand swept around smoothly. Another door led into an adjoining supply room, shared with OR No. 10, which contained the sterilizers and other paraphernalia.

Susan spent almost an hour going over room No. 8, as well as No. 10 for comparison. She found nothing abnormal or even mildly curious about room No. 8. It was an OR room like so many thousands. No. 10 appeared no different.

Without challenge, Susan retraced her steps to the nurses’ locker room and changed back into her nurse’s uniform. She threw her scrub dress into a hamper and started for the door. But she paused then, looking up at the ceiling. It was a drop ceiling, made with large blocks of acoustical tile.

The wastebasket provided an intermediate step. Susan moved from the wastebasket to the sink to the
top of the lockers. The ceiling was about three feet above the top of the lockers. Crouching on all fours, she tried the first ceiling block. It would not lift up because of some piping immediately above it. She tried another. Same problem. The third tile, however, lifted easily, and Susan slid it to one side. She then stood up on top of the locker, projecting half of herself into the ceiling space. Contrary to her estimate, the ceiling space was generous in its size. There was almost five feet of vertical space from the dropped acoustical ceiling to the cement of the floor slabs above. A myriad of pipes and ducts ran through this space, carrying the hospital’s vital supplies and wastes. The light was very poor, with only pencil-like beams seeping up from below in scattered locations between ceiling tiles.

The dropped ceiling was composed of the cardboard tile, held in place by thin metal strips, which were in turn hung from the cement slab above. Neither the tiles nor the metal strips were strong enough to carry any weight. In order to enter the ceiling space, Susan had to pull herself up onto the pipes, which she found either ice cold or very hot. Once up in the ceiling space, she replaced the ceiling tile she had moved. It fell back into place, cutting off the direct source of light.

Susan waited until her eyes made the adjustment from the fluorescent world below to the semidarkness above. Eventually outlines took forms and Susan could move ahead along the pipes. She noticed a row of studs which continued through the ceiling space to connect with the concrete above. She guessed that they marked the wall of the corridor.

Progress was slow; it was difficult to move on the pipes, treading on one, keeping hold of another or, here and there, a stud for support. She did not want to make any noise, especially when she guessed she was over the area of the main desk. Once over the OR area itself, the going became definitely easier. The ceilings over the OR and the recovery room were fixed and made of prestressed concrete. Susan could move at will provided she avoided tripping on the piping and provided she bent over considerably, for the space here was only about three feet high.

Susan found a concrete wall which she guessed housed the elevator shafts. Then she discovered that the corridor of the OR area had a dropped ceiling. Beyond the OR corridor, over what was probably part of central supply, Susan could see that the maze of pipes and ducts running through the ceiling space converged
in what seemed a tangled vortex. Susan guessed that was the location of the central chase which housed all the piping and ducts coursing vertically in the building.

Susan was interested primarily in locating room No. 8. But that was not easy. There were no specific demarcations from one OR to the next. The pipes seemed to spread out and dive through the concrete to the operating rooms below in utter anarchy. The corridor ceiling led to a solution. By carefully picking up the edges of the ceiling blocks over the corridor, Susan was able to orient herself and locate the ceiling area of rooms No. 8 and No. 10. Susan satisfied herself that the number and configuration of the pipes to and from the two rooms were identical.