Coma

by Robin Cook

  “About how many such cases would you estimate?”

  “Over what time span?”

  “Whatever . . . a year, two years.”

  “Maybe six or seven over the last two years. I’m guessing.”

  “And you don’t have any ideas about the cause of death?”

  “Nope.”

  “None?” asked Susan, a bit surprised.

  “Well, I think it’s something with the brain. Something turns off their breathing. Maybe a stroke, but I did brain sections like you wouldn’t believe on two similar cases.”

  “And?”

  “Nothing. Clean as a whistle.”

  Susan began to feel a bit queasy. The atmosphere, the smell, the images, the noises all joined forces to make her feel light-headed and she shuddered with a mild wave of nausea. She swallowed.

  “Are the hospital charts for Ferrer and Crawford down here?”

  “Sure, they’re in the coffee room through the lab.”

  “I’d like to look at them for a few minutes. If you find anything significant, would you give me a yell? I’d be interested in seeing it.”

  The taller resident lifted the heart and placed it on the scale. “These your patients?”

  “Not exactly,” said Susan, starting toward the exit, “but they might be.”

  The taller resident looked quizzically over at the other as Susan left. His companion was watching Susan exit, trying to figure out a smooth way of getting her name and number.

  The coffee room could have been anywhere in the hospital. The coffee machine was an ancient device, the paint on one side burned and the wire frayed to the point of being a real hazard. The countertop desk along both side walls was spread with charts, paper, books, coffee cups, and a welter of ballpoint pens.

  “That was quick,” said the resident who had been staining the slides. He was sitting at one of the desks, with a half-filled cup of coffee and a half-eaten doughnut. He was busy signing a large stack of typed pathology reports.

  “Autopsies are apparently too much for me,” admitted Susan.

  “You get used to it, like everything else,” said the resident, stuffing more doughnut into his mouth.

  “Possibly. Where would I look for the charts of the patients they are posting?”

  The resident washed down the doughnut with coffee, swallowing with some effort.

  “In that shelf marked ‘Post.’ When you finish with them, put them over there in the shelf marked ‘Medical Records’ because we’re finished with them.”

  Turning to the rear wall, Susan faced a series of cubic shelves. One of the shelves was marked “Post.” On it she found Ferrer’s and Crawford’s charts. Clearing one of the desks of debris, Susan sat down and took out her notebook. At the top of an empty page she wrote, “Crawford,” on the top of another page she wrote, “Ferrer.” Methodically she began to extract the charts as she had done with Nancy Greenly’s.

  Tuesday

  February 24

  8:05 A.M.

  Susan had found it unbelievably difficult to emerge from the warmth and comfort of her bed when the radio alarm went off the following morning. The fact that it was a Linda Ronstadt selection was a big help in that it caused some degree of pleasant association in Susan’s mind and instead of turning the radio off, she lay there and let the sounds and rhythm course through her. By the time the song was over Susan was fully awake, her mind beginning to race over the events of the previous day. The night before, at least until three A.M., had been passed in deep concentration with the large pile of journal articles, the books on anesthesiology, her own internal medicine book, and her clinical neurology text. She had amassed an enormous amount of notes, and her bibliography had increased to some one hundred articles that she planned to drag from the library stacks. The project had become more complex, more demanding, yet at the same time more fascinating, more absorbing. As a consequence Susan had become even more determined, and she realized that she was going to have to accomplish a great deal that day.

  Shower, dressing, and breakfast were dispatched with commendable speed. During breakfast, she reread some of her notes, realizing that she would have to reread the last few articles she had read the night before.

  The walk to the MBTA stop on Huntington Avenue proved to Susan that the weather had not changed and she cursed the fact that Boston had to be situated so far north. With luck she found a seat on the aging streetcar and was able to unfold a portion of her IBM printout. She wanted to check once more the number of cases which it suggested.

  “Good to see you, Susan. Don’t tell me you’re going to go to lecture today?”

  Susan looked up into the grinning face of George Niles, who was holding on to the bar above her head.

  “I’d never miss lecture, George; you know that.”

  “Looks like you missed rounds. It’s after nine.”

  “I could say the same to you.” Susan’s tone hovered between being friendly and combative.

  “I was told in no uncertain terms that I had to be seen in Student Health to rule out a comminuted compound skull fracture from yesterday’s gala event in the OR.”

  “You are OK, aren’t you?” asked Susan with genuine sincerity and concern.

  “Yeah, I’m fine. It’s just hard to patch up my injured ego. That was the only thing that broke. But the clinic doc said that the ego had to heal itself.”

  Susan allowed herself to laugh. Niles joined. The car stopped at Northeastern University.

  “Missing half of your first day at Surgery at the Memorial, then skipping rounds the next day, that’s commendable, Miss Wheeler.” George assumed a serious expression. “In no time at all you’ll be able to run for medical student Phantom of the Year. If you keep it up you’ll be able to challenge the record set by Phil Greer during second-year Pathology.”

  Susan didn’t answer. She went back to her IBM sheets.

  “What are you working on, anyway?” asked Niles, twisting himself in an attempt to view the printout right side up.

  Susan looked up at Niles. “I’m working on my Nobel Prize acceptance speech. I’d tell you about it but you might miss lecture.”

  The car plunged down into the tunnel, beginning its transit under the city. Conversation became impossible. Susan resumed her check of the IBM printout sheet. She wanted to be damn sure of the numbers.

  With its private offices Beard 8 resembled Beard 10. Susan walked down the corridor, stopping at room 810. The door had crisp black lettering across its aged but polished mahogany surface: “Department of Medicine, Professor J. P. Nelson, M.D., Ph.D.”

  Nelson was Chief of Medicine, Stark’s counterpart, but associated with internal medicine and its subspecialties. Nelson was also a powerful figure in the medical center but not quite as influential as Stark, nor was he as dynamic, and as a fund-raiser, he couldn’t even compare. Nevertheless, it took a bit of fortitude on Susan’s part to get up the nerve to approach this Olympian figure. With some hesitation she pushed open the mahogany door and faced a secretary with wire-rimmed glasses and a comfortable smile.

  “My name is Susan Wheeler and I called a few minutes ago to see Dr. Nelson.”

  “Yes of course. You’re one of our medical students?”

  “That’s right,” said Susan, unsure of what “our” meant in that context.

  “You’re lucky, Miss Wheeler, to catch Dr. Nelson in. Plus I believe he remembers you from a class or something. Anyway, he’ll be with you shortly.”

  Susan thanked her and retreated to one of the stiff black waiting-room chairs. She pulled out her notebook to scan more of her notes, but instead found herself viewing the room, the secretary, and the lifestyle it meant for Dr. Nelson. As far as the value system in medical school was concerned, such a position represented the final triumph of years of effort and even luck. It was just the kind of luck Susan felt could be behind her present quest. All someone needed was one lucky break and the doors would open.

  The reverie was cut short by t
he door to the inner office being opened. Two doctors in long white coats came from within, continuing their conversation at the door. Susan could get bits and pieces and it seemed to be about an enormous amount of drugs that had been located in a locker in the surgical lounge. The younger of the two men was quite agitated and spoke in a whisper whose sound level was approximately equal to normal speech. The other gentleman had the portly bearing of a mature physician, replete with soft, knowing eyes, luxuriant graying hair, and a consoling smile. Susan knew it had to be Dr. Nelson. He seemed to be trying to console the other with reassuring words and a lingering pat on the shoulder. Once the other doctor had left, Dr. Nelson turned to Susan and beckoned for her to follow him.

  Nelson’s office was a tumble of reprinted journal articles, scattered books, and stacks of letters. It appeared as if a tornado had swept through the room several years previously with no subsequent effort at reconstruction. The furniture consisted of a large desk and an old cracked leather chair that squeaked as Dr. Nelson lowered his weight into it. There were two other smaller leather chairs facing the desk. Susan was motioned to take one of them as Dr. Nelson took one of his briars and opened a tobacco canister on the desk. Before filling the pipe he hit it on the palm of his left hand a few times. The few ashes that appeared were carelessly scattered on the floor.

  “Ah yes, Miss Wheeler,” began Dr. Nelson, scanning a note card on his desk. “I remember you well from physical diagnosis class. You were from Wellesley.”

  “Radcliffe.”

  “Radcliffe, of course.” Dr. Nelson corrected his note card. “What can we do for you?”

  “I’m not sure how to start. But I’ve become very interested in the problem of prolonged coma, and I have begun to look into it.”

  Dr. Nelson leaned back, the chair squeaking in agony. He placed the tips of his fingers together.

  “That’s fine, but coma is a big subject, and, more important, it is a symptom rather than a disease in itself. It is the cause of the coma that is important. What is the cause of the coma you have become interested in?”

  “I don’t know. In short, that’s why I’m interested in it. I’m interested in the kind of coma that just seems to happen and no cause is found.”

  “Are you concerned with emergency room patients or in-hospital patients?” asked Dr. Nelson, whose voice changed slightly.

  “Inpatients.”

  “Are you referring to the few cases that have occurred during surgery?”

  “If you call seven few.”

  “Seven,” said Dr. Nelson taking several long pulls from his pipe, “I believe is a rather high estimate.”

  “It’s not an estimate. Six previous cases occurred during surgery. Presently there is another case upstairs, operated on yesterday, that appears to fit into the same category. In addition, there have been at least five cases on the medical floor occurring in patients admitted for some seemingly unrelated complaint.”

  “How did you get this information, Miss Wheeler?” asked Dr. Nelson with an altogether different tone of voice. The previous warmth was gone. His eyes regarded Susan without blinking. Susan was unaware of this change in apparent mood.

  “I got the information from this computer printout right here.” Susan leaned forward with the printout and handed it across the desk to Dr. Nelson. “The cases I’ve mentioned have been indicated with yellow ink. You’ll see that there is no mistake. Besides, this represents only coma cases for the last year. I don’t know what the incidence was before then, and I think it would be essential to get a year-by-year printout. In that way one could have a better idea if this problem is static or on a dynamic upswing. And perhaps even more important, or at least equally important, I have a feeling that a number of sudden deaths here at the Memorial could be ascribed to the same unknown category. I believe the computer could help on that as well. Anyway, it is for these reasons that I wanted to speak with you. I was wondering if you would support me on this endeavor. What I need is full clearance to use the computer and the opportunity to get the hospital charts on these patients. I came to you because I have an intuitive feeling that it represents some sort of unknown medical problem.”

  With her case presented, Susan allowed herself to sit back into the chair. She felt she had put the matter fairly and completely; if Dr. Nelson was going to be interested, he certainly had enough to go on to make up his mind.

  Dr. Nelson did not speak right away. Instead he continued to regard Susan; then he studied the printout, taking short, quick puffs on his pipe.

  “This is all very interesting information, young lady. Of course I have been aware of the problem. However, there are other implications in these statistics and I can assure you that this apparent high incidence is occurring because . . . well, frankly . . . we have been lucky over the last five or six years that we haven’t had any such cases. Statistics have a way of catching up with you, though . . . and indeed that seems to be the case at present. As to your request, I’m afraid I’m not in a position to grant it. You undoubtedly understand one of the major impediments to our establishing our central computer information bank was the creation of adequate safeguards concerning the confidentiality of most of the information stored. It is impossible for me to give blanket authorization. In fact, this type of endeavor is really . . . what should I say . . . hmm . . . beyond . . . or above that which a medical student of your level is equipped to deal with. I think it would be in everyone’s best interest, yours included, if you would limit your research interests to more scientific projects. I’m certain I could find room for you in our liver lab, if you were interested.”

  Susan was so accustomed to academic encouragement that she was totally caught off guard by Dr. Nelson’s negative response to her investigation. Not only was he not interested, but he was obviously trying to talk Susan out of the project as well.

  Susan hesitated, then stood up.

  “Thank you very much for the offer. But I’ve just gotten so involved with this study that I think I’ll follow it up for a while.”

  “Suit yourself, Miss Wheeler. But I’m sorry; I cannot help you.”

  “Thank you for your time,” said Susan, reaching out for her computer printout.

  “I’m afraid this information cannot be made available for you any longer,” said Dr. Nelson interposing his hand between Susan’s and the IBM sheet.

  Susan kept her hand extended for a second of indecision. Once again Dr. Nelson had caught her off guard with an unexpected response. It seemed absurd that he would actually have the gall to confiscate material she already had.

  Susan did not say another word and she avoided looking at Dr. Nelson. She got her things together and left. Dr. Nelson instantly picked up the telephone and placed a call.

  Tuesday

  February 24

  10:48 A.M.

  In Dr. Harris’s office there was an entire bookcase full of the latest books on anesthesiology, some still in prepublication bound galleys, sent for his endorsement. For Susan this was a boon, and her eyes scanned the titles for any books specifically on complications. She located one, and she wrote down the title and publisher. Next she looked for any general texts which she had not seen in the library. And her eyes registered another find: Coma: Pathophysiological Basis of Clinical States. Excitedly she withdrew the volume and thumbed through it, noticing the chapter headings. She wished she had had the book at the onset of her reading.

  The door to the office opened and Susan looked up to face Dr. Robert Harris for the second time. Instantly she felt a certain sense of intimidation or scorn as Dr. Harris regarded her without the slightest sign of recognition or friendliness. It had not been Susan’s idea to wait for him in his office; it had been the direct order of the secretary who had arranged the meeting for Susan. Now Susan felt an uneasiness, as if she were an interloper in Dr. Harris’s private sanctum. The fact that she was holding one of his books made it that much worse.

  “Be sure to put the volume back where you found i
t,” said Harris as he turned to close the door, his speech slow and deliberate as if addressed to a child. He removed his long white coat and hung it on the hook on the back of the door. Without another word he retreated behind his desk to open a large ledger and make several notations. He acted as if Susan were not even there.

  Susan closed the textbook and replaced it on the shelf. Then she returned to the director’s chair in which she had started her wait for Dr. Harris thirty minutes before.

  The only window was directly behind Harris, and its light, combining with the overhead fluorescent light, gave a strange shimmering quality to Harris’s appearance. Susan had to squint against the glare coming directly at her.

  The smooth tawny color of Harris’s arms was a perfect setting for the gold digital watch on his left wrist. His forearms were massive, tapering to surprisingly narrow shafts. Despite the time of year and the temperature, Dr. Harris was dressed in a short-sleeved blue shirt. Several minutes went by before he finished with the ledger. After closing the cover he pressed a buzzer for his secretary to come in and take it. Only then did he turn and acknowledge Susan’s existence.

  “Miss Wheeler, I am certainly surprised to see you in my office.” Dr. Harris slowly leaned back in his chair. He seemed to have some difficulty looking directly at Susan. Because of the background lighting Susan could not see the details of his face. His tone was cold. There was a silence.

  “I would like to apologize,” began Susan, “for my apparent impertinence yesterday in the recovery room. As you probably are aware, this is my first clinical rotation, and I’m unaccustomed to the hospital environment, particularly to the recovery room. On top of that there had been a strange coincidence. About two hours prior to our meeting I had spent some time with the very patient you were attending. I had started his I.V. prior to surgery.”